Anthem/Elevance Health Shoulder Arthroscopy Rotator Cuff Repair prior authorization requirements (2026)
What Anthem/Elevance Health generally requires to approve Shoulder Arthroscopy Rotator Cuff Repair (CPT 29827), for Commercial plans. Yes. Anthem/Elevance Health generally requires prior authorization for Shoulder Arthroscopy Rotator Cuff Repair (CPT 29827).
Medical-necessity criteria Anthem/Elevance Health generally applies
(1) MRI confirming rotator cuff tear (full-thickness or partial ≥50%); (2) Symptoms ≥6 weeks; (3) Formal PT failure ≥6 weeks with rotator cuff-specific protocol; (4) Documented functional deficit (ROM limitation, weakness, ADL impairment); (5) AIM/Carelon pathway if plan-routed
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 Anthem/Elevance Health policy.
Commonly required documentation
- MRI with tear characterization
- PT records
- shoulder functional scores
- ROM and strength
- AIM authorization if applicable
How to submit
- Portal: Availity / Anthem Provider Portal
- Typical turnaround: about 3 days
Sources & verification
- BindingSource — Clinical Appropriateness Guidelines — Joint Surgery (Anthem delegates MSK joint surgery to Carelon) (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.
Frequently asked questions
Does Anthem/Elevance Health require prior authorization for Shoulder Arthroscopy Rotator Cuff Repair?
Yes. Anthem/Elevance Health generally requires prior authorization for Shoulder Arthroscopy Rotator Cuff Repair (CPT 29827).
What does Anthem/Elevance Health require to approve Shoulder Arthroscopy Rotator Cuff Repair?
(1) MRI confirming rotator cuff tear (full-thickness or partial ≥50%); (2) Symptoms ≥6 weeks; (3) Formal PT failure ≥6 weeks with rotator cuff-specific protocol; (4) Documented functional deficit (ROM limitation, weakness, ADL impairment); (5) AIM/Carelon pathway if plan-routed Always confirm against the current Anthem/Elevance Health policy.
How long does a Anthem/Elevance Health prior authorization take?
Anthem/Elevance Health typically decides Shoulder Arthroscopy Rotator Cuff Repair requests in about 3 days. Timeframes vary; check the payer portal.
Submitting Shoulder Arthroscopy Rotator Cuff Repair to Anthem/Elevance Health?
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.