Shoulder Arthroplasty (Total, Partial, Reverse, Revision and Resurfacing) - (Effective Date - 2026-10-15) 7.01.95

By October 15, 2026: Billing and clinical teams must implement new prior authorization protocols for all shoulder arthroplasty procedures covered under policy 7.01.95. (1) Update billing system to route shoulder arthroplasty cases for prior authorization with specific medical necessity checklist; (2) Providers must document in all shoulder replacement cases: (a) radiographic/advanced imaging findings confirming destructive joint disease with specific findings listed (irregular surfaces, glenoid sclerosis, osteophytes, flattened glenoid, or cystic changes), (b) duration of function-limiting pain (minimum 3 months for total/hemi/reverse, 6 months for revisions), (c) proof of failed conservative management for required duration; (3) Front desk/prior auth staff must verify cases do NOT have exclusion criteria (active infection, paralytic disorders, uncontrolled medical conditions, Charcot joint, or for hemi-arthroplasty—rotator cuff tear arthropathy); (4) STOP billing shoulder resurfacing procedures—these are classified as investigational and non-covered; (5) For reverse total arthroplasty specifically, document deltoid muscle functional use on physical exam; (6) Educate providers that revision arthroplasty requires 6 months of failed conservative management (longer than primary procedures). Update encounter forms, EMR templates, and prior auth submission requirements. Claims submitted without proper documentation of medical necessity criteria will be denied.