Medicare AdvantagePrior AuthHigh impact
Shoulder Arthroscopy - Medicare Advantage (Revised)
Humana·Orthopedics, General Surgery, Sports Medicine·Medicare Advantage
Effective date
Sep 11, 2026
We identified it
Sep 10, 2026
Summary
Humana Medicare Advantage has issued a revised shoulder arthroscopy coverage policy (HUM-1287-002) effective 09/11/2026, establishing medical necessity criteria for four shoulder arthroscopy procedures: calcific tendonitis, capsular adhesions (frozen shoulder), capsular instability/laxity, and distal claviculectomy. The policy requires specific documentation, imaging, physical exam findings, and conservative management periods (6-12 months depending on condition) before surgery is covered.
Action Required
By September 11, 2026: (1) Billing team must update prior authorization requirements in billing system to enforce Humana Medicare Advantage coverage criteria for all shoulder arthroscopy codes (29805-29807, 29819-29825). (2) Providers must document: radiological interpretation (X-ray, MRI, CT, or ultrasound), physical exam findings (function-limiting pain, reduced ROM), and proof of conservative management failure (6 months for calcific tendonitis/instability; 12 months for frozen shoulder) including physical therapy and at least one of: activity modification, intra-articular steroid injection, or NSAIDs/non-opioid analgesics. (3) Front desk and clinical staff must add checklist to EMR templates requiring documentation of all criteria before scheduling. (4) Ensure intra-articular steroid injections are avoided 1 month prior to planned arthroscopic surgery. Claims submitted without complete documentation of all criteria will be denied. Contact Palmetto GBA (MACs JJ/JM) in AL, GA, TN, NC, SC, VA, WV for jurisdiction-specific questions.