Shoulder Arthroplasty and Arthrodesis (CPB 0837, reviewed 2026-06-25)

By June 25, 2026: Billing and clinical teams must implement the following: (1) Update prior authorization protocols in billing system to require documentation of conservative therapy requirements—specifically minimum 12 weeks of non-surgical treatment with at least 6 weeks of in-person formal PT by a licensed physical therapist within the past year; (2) Create/update claim submission checklists to ensure providers document imaging evidence of advanced joint disease (glenohumeral arthritis, AVN, post-traumatic arthritis, RA), pain duration of 6+ months, functional disability affecting ADLs, and unsuccessful conservative therapy attempts; (3) Update encounter templates in EMR to prompt providers to document all conservative therapy components (anti-inflammatory meds, PT exercises, activity modification, steroid injections where applicable, or document why conservative therapy is contraindicated); (4) Train front-desk and billing staff that precertification is required for select shoulder arthroplasty/arthrodesis procedures—use Aetna's CPT code search tool to identify which specific codes require pre-auth; (5) For reverse shoulder arthroplasty claims, ensure documentation includes deltoid integrity, adequate bone stock assessment, passive ROM ≥90 degrees, and absence of conditions causing excessive implant stress; (6) For arthrodesis claims, verify imaging confirms diagnosis and document chronic severe pain with ADL interference. Failure to obtain precertification and submit complete medical necessity documentation per these criteria will result in claim denials or payment delays.