All PlansCoverageHigh impact
Shoulder Arthroplasty (Total, Partial, Reverse, Revision and Resurfacing) 7.01.95
Excellus BlueCross BlueShield·NY · Orthopedics, Rheumatology, Sports Medicine +1 more·Bone & Joints (Orthopedic)
Effective date
Oct 15, 2025
We identified it
Jul 16, 2026
Summary
Excellus BlueCross BlueShield has issued a comprehensive new medical policy (7.01.95, effective October 15, 2025) establishing specific clinical criteria and medical necessity requirements for shoulder arthroplasty procedures including total, partial (hemi), reverse, and revision surgeries. The policy defines exact diagnostic, functional, and conservative treatment prerequisites that must be met before authorization; procedures not meeting these criteria or performed on patients with contraindications (active infection, paralytic disorders, uncontrolled medical conditions, Charcot joint) will be considered not medically necessary and denied. Shoulder resurfacing is classified as investigational.
Action Required
By October 15, 2025: Billing and pre-authorization teams must immediately implement this policy as a hard stop in prior authorization workflows. (1) Update prior authorization system to require documentation of ALL mandatory criteria before claim approval for: total shoulder arthroplasty (radiographic evidence of advanced DJD with specific glenoid/humeral findings, 3+ months function-limiting pain, 3+ months failed conservative care); hemi-arthroplasty (inadequate glenoid bone stock OR AVN without glenoid involvement OR non-fixable proximal humerus fracture, plus 3+ months pain/failed conservative care); reverse shoulder arthroplasty (rotator cuff tear pathology with deltoid function, glenoid retroversion with Walch B2/B3/C classification, OR posterior humeral head subluxation >50%, plus 3+ months pain/failed conservative care); and revision arthroplasty (recurrent dislocation, component instability, aseptic loosening, periprosthetic infection/fracture, OR 6+ months unexplained pain unresponsive to conservative care). (2) Configure system to automatically DENY claims for patients with contraindications: active local/systemic infection, paralytic shoulder disorders, uncontrolled/unstable cardiac/pulmonary/liver/genitourinary/metabolic disease or hypertension, abnormal electrolytes, or Charcot joint. (3) Create pre-authorization checklist for providers including required imaging (radiographs, MRI, or CT with specific findings), physical exam documentation of deltoid function (for reverse procedures), timeline of symptoms (minimum 3 months function-limiting pain), and evidence of failed provider-directed non-surgical management (minimum 3 months). (4) Flag all shoulder resurfacing requests (total, hemi, or partial) as investigational—deny and direct to Policy 11.01.03. (5) Train authorization staff on the distinction between procedure types, as criteria differ significantly. (6) Communicate policy immediately to all orthopedic providers, physiatrists, and rheumatology practices submitting shoulder arthroplasty claims. Claims submitted without documented compliance will be denied.