Anthem/Elevance Health Total Shoulder Arthroplasty prior authorization requirements (2026)
What Anthem/Elevance Health generally requires to approve Total Shoulder Arthroplasty (CPT 23472), for Commercial plans. Yes. Anthem/Elevance Health generally requires prior authorization for Total Shoulder Arthroplasty (CPT 23472).
Medical-necessity criteria Anthem/Elevance Health generally applies
(1) Severe glenohumeral arthritis on X-ray; (2) Conservative care failure ≥3 months; (3) ASES <50 AND forward elevation <120°; (4) Anatomic: intact/reparable cuff; Reverse: massive irreparable cuff with intact deltoid; (5) CT if significant glenoid bone loss
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 Anthem/Elevance Health policy.
Commonly required documentation
- Shoulder X-rays
- MRI
- ASES score and ROM
- conservative care records
- surgeon implant selection rationale
How to submit
- Portal: Availity / Anthem Provider Portal
- Typical turnaround: about 3 days
Source
Specify implant type — anatomic vs. reverse has distinct criteria. Bone loss patterns (Walch type B2+) may require CT glenoid for implant planning.
Frequently asked questions
Does Anthem/Elevance Health require prior authorization for Total Shoulder Arthroplasty?
Yes. Anthem/Elevance Health generally requires prior authorization for Total Shoulder Arthroplasty (CPT 23472).
What does Anthem/Elevance Health require to approve Total Shoulder Arthroplasty?
(1) Severe glenohumeral arthritis on X-ray; (2) Conservative care failure ≥3 months; (3) ASES <50 AND forward elevation <120°; (4) Anatomic: intact/reparable cuff; Reverse: massive irreparable cuff with intact deltoid; (5) CT if significant glenoid bone loss Always confirm against the current Anthem/Elevance Health policy.
How long does a Anthem/Elevance Health prior authorization take?
Anthem/Elevance Health typically decides Total Shoulder Arthroplasty requests in about 3 days. Timeframes vary; check the payer portal.
Submitting Total Shoulder Arthroplasty 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.