Aetna Total Shoulder Arthroplasty prior authorization requirements (2026)
What Aetna generally requires to approve Total Shoulder Arthroplasty (CPT 23472), for Commercial plans. Yes. Aetna generally requires prior authorization for Total Shoulder Arthroplasty (CPT 23472).
Medical-necessity criteria Aetna generally applies
Aetna (CPB 0837) considers total shoulder arthroplasty medically necessary for advanced glenohumeral joint disease with pain and functional disability limiting activities of daily living, reduced range of motion or crepitus on exam, severe pain and loss of function of at least 6 months, radiographic destructive disease (2 or more of: irregular surfaces, glenoid sclerosis, osteophytes, flattened glenoid, cystic changes, joint-space narrowing), and at least 12 weeks of documented unsuccessful conservative therapy (anti-inflammatories, flexibility/strengthening exercise, activity modification, supervised physical therapy). Reverse arthroplasty additionally for deficient rotator cuff with glenohumeral arthropathy, failed prior arthroplasty, massive cuff tears with pseudoparalysis, tumor, or non-repairable proximal humeral fracture (intact deltoid, adequate bone stock, at least 90 degrees passive elevation). Excludes active joint/systemic/skin infection, corticosteroid injection within 12 weeks, rapidly progressive neurological disease, or implant allergy.
Diagnoses that commonly support medical necessity
ICD-10-CM diagnoses frequently associated with medical necessity for Total Shoulder Arthroplasty. Confirm the covered diagnosis list against the current Aetna policy.
Source
Summarized from Aetna Clinical Policy Bulletin 0837 (Shoulder Arthroplasty and Arthrodesis). Source: View the source policy. Last verified 2026-06-14.
Frequently asked questions
Does Aetna require prior authorization for Total Shoulder Arthroplasty?
Yes. Aetna generally requires prior authorization for Total Shoulder Arthroplasty (CPT 23472).
What does Aetna require to approve Total Shoulder Arthroplasty?
Aetna (CPB 0837) considers total shoulder arthroplasty medically necessary for advanced glenohumeral joint disease with pain and functional disability limiting activities of daily living, reduced range of motion or crepitus on exam, severe pain and loss of function of at least 6 months, radiographic destructive disease (2 or more of: irregular surfaces, glenoid sclerosis, osteophytes, flattened gl… Always confirm against the current Aetna policy.
How long does a Aetna prior authorization take?
Turnaround varies by plan and submission method. Check the Aetna portal for current timeframes.
Submitting Total Shoulder Arthroplasty to Aetna?
Praxigen checks your clinical note against these criteria before you submit and drafts a policy-cited appeal if it is denied. You review and submit; nothing is sent automatically.