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Shoulder Arthroplasty - Medicare Advantage (Revised)
Effective date
Aug 3, 2026
Identified
Aug 4, 2026
Summary
Humana Medicare Advantage has updated its shoulder arthroplasty coverage policy (HUM-1207-008), effective 08/03/2026. The policy establishes medical necessity criteria for total shoulder arthroplasty (TSA), reverse total shoulder arthroplasty (rTSA), hemi-arthroplasty, and revision procedures, with specific documentation and conservative treatment requirements that billing teams must verify before claim submission.
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What to do
Action · 8 steps
01By 07/15/2026: Billing team must update prior authorization workflows and claim validation rules in billing system for all shoulder arthroplasty procedures (CPT 23335, 23470, 23472, 23473, 23474) under Humana Medicare Advantage plans.
02Update documentation checklists to require: (1) imaging reports (X-ray, CT, or MRI), (2) evidence of conservative treatment failure (activity modification, injections, NSAIDs, or physical therapy), (3) documentation of disabling pain and functional disability, and (4) confirmation of FDA-approved device use.
03For hemi-arthroplasty (23470), add verification steps to confirm absence of active infection, deltoid deficiency, inadequate bone stock, neuropathic arthropathy, and paralytic disorders.
04For revision procedures (23335, 23473, 23474), confirm device failure or complication of prior arthroplasty.
05Train providers and billing staff on required documentation elements.
06Update intake forms and encounter templates with medical necessity checkpoints.
07Coordinate with Palmetto GBA (MAC JJ and JM) for jurisdictions AL, GA, TN, NC, SC, VA, WV, which follow LCD L39956.
08All claims submitted without complete medical necessity documentation will be denied or require additional review, delaying payment and causing claim rework.
Codes mentioned
2333523470234722347323474
Original notice
Shoulder Arthroplasty - Medicare Advantage (Revised)
mcp.humana.com · Always check the source before changing claims.