AIM (out-of-state / Federal BCBS) Shoulder Arthroscopy Rotator Cuff Repair prior authorization requirements (2026)
What AIM (out-of-state / Federal BCBS) generally requires to approve Shoulder Arthroscopy Rotator Cuff Repair (CPT 29827), for commercial plans. Yes. AIM (out-of-state / Federal BCBS) generally requires prior authorization for Shoulder Arthroscopy Rotator Cuff Repair (CPT 29827).
Medical-necessity criteria AIM (out-of-state / Federal BCBS) generally applies
Prior authorization via Carelon. Acute full-thickness rotator cuff tear: traumatic injury within 3 months, no preexisting shoulder pain, VAS at least 4, cuff weakness, at least one positive special test (drop-arm, painful arc, full/empty can), and advanced imaging confirming the tear — no conservative-therapy waiting period. Chronic/degenerative full-thickness tear: gradual onset, VAS at least 4 interfering with ADLs, cuff weakness, positive test, confirmatory imaging, AND failure of at least 6 weeks conservative management. Partial-thickness: same plus symptoms at least 3 months and at least 6 weeks failed conservative care. Carelon Joint Surgery MSK02-1125.1.
Diagnoses that commonly support medical necessity
ICD-10-CM diagnoses frequently associated with medical necessity for Shoulder Arthroscopy Rotator Cuff Repair. Confirm the covered diagnosis list against the current AIM (out-of-state / Federal BCBS) policy.
How to submit
- Method: Carelon ProviderPortal
- Portal: Carelon Medical Benefits Management
Sources & verification
- BindingSource — Carelon Clinical Appropriateness Guidelines — Joint Surgery (MSK02-1125.1) · effective 2025-11-15.View
Binding = the payer's own policy. Proxy = a public, evidence-based clinical guideline the payer mirrors. Portal-only = the binding criteria are confirmed in the administrator's portal. Always confirm against the payer for the member's specific plan. Last verified 2026-06-26.
Frequently asked questions
Does AIM (out-of-state / Federal BCBS) require prior authorization for Shoulder Arthroscopy Rotator Cuff Repair?
Yes. AIM (out-of-state / Federal BCBS) generally requires prior authorization for Shoulder Arthroscopy Rotator Cuff Repair (CPT 29827).
What does AIM (out-of-state / Federal BCBS) require to approve Shoulder Arthroscopy Rotator Cuff Repair?
Prior authorization via Carelon. Acute full-thickness rotator cuff tear: traumatic injury within 3 months, no preexisting shoulder pain, VAS at least 4, cuff weakness, at least one positive special test (drop-arm, painful arc, full/empty can), and advanced imaging confirming the tear — no conservative-therapy waiting period. Chronic/degenerative full-thickness tear: gradual onset, VAS at least 4 i… Always confirm against the current AIM (out-of-state / Federal BCBS) policy.
How long does a AIM (out-of-state / Federal BCBS) prior authorization take?
Turnaround varies by plan and submission method. Check the AIM (out-of-state / Federal BCBS) portal for current timeframes.
Submitting Shoulder Arthroscopy Rotator Cuff Repair to AIM (out-of-state / Federal BCBS)?
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.