Blue Cross NC Total Shoulder Arthroplasty prior authorization requirements (2026)

Medical-necessity criteria Blue Cross NC generally applies

Specific Requirements (all shoulder arthroplasty) - "ALL the following conditions must be present regardless of the indication for which the procedure is being performed: Anticipated level of function should place limited demands on the shoulder joint; Deltoid muscle must be functioning; Shoulder joint must be anatomically and structurally suited to receive selected implants (i.e., adequate bone stock to allow for firm fixation of implant)." Total Shoulder Arthroplasty - "Total shoulder arthroplasty is considered medically necessary for ANY of the following indications: Proximal humerus fracture confirmed by imaging not amenable to internal fixation (e.g., severe comminution, poor bone quality, multipart, displaced); Malignancy involving the glenohumeral joint or surrounding soft tissue; Advanced joint disease of the shoulder due to osteoarthritis, rheumatoid arthritis, avascular necrosis (osteonecrosis), or post-traumatic arthritis when ALL the following requirements are met: Limited range of motion or crepitus of the glenohumeral joint on physical examination; Pain and loss of function of at least 6 months duration that interferes with daily activities (unless radiographs show Kellgren-Lawrence grade 4); Radiographic evidence of destructive degenerative joint disease as evidenced by marked joint space narrowing AND ONE or more of the following: Irregular joint surfaces; Glenoid sclerosis; Osteophyte changes; Flattened glenoid; Cystic changes in the humeral head; Failure of conservative management of at least 6 weeks duration (unless radiographs show Kellgren-Lawrence grade 4 or diffuse modified Outerbridge grade III-IV changes)." Reverse Shoulder Arthroplasty - "considered medically necessary for ANY of the following indications: Reconstruction after a tumor resection; Glenoid bone stock/anatomy inadequate to support a glenoid prosthesis; Failed hemiarthroplasty; Failed total shoulder arthroplasty with non-repairable rotator cuff; Shoulder fracture that is not repairable or cannot be reconstructed with other techniques; Glenohumeral osteoarthritis confirmed by imaging with irreparable rotator cuff tear, impairment of function for 6 months, and failure of conservative management for at least 6 weeks duration (unless radiographs show Kellgren-Lawrence grade 4); Advanced joint disease of the shoulder when criteria for total shoulder arthroplasty are met AND ... Deficient rotator cuff with limited ability to actively flex the upper extremity above the plane of the shoulder." Hemiarthroplasty - fracture/malignancy indications as above, or TSA criteria met AND at least ONE of: osteonecrosis of the humeral head without glenoid involvement; glenoid bone stock inadequate to support a glenoid prosthesis; advanced joint disease due to rotator cuff tear arthropathy; glenohumeral osteoarthritis with irreparable rotator cuff tear. [NEEDS CLINICAL SPOT-CHECK]

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 Blue Cross NC policy.

Commonly required documentation

• Documentation supporting medical necessity and a clearly stated plan of care should be submitted at the time of the request and must include the following components: Clinical notes describing symptom duration and severity, specific functional limitations related to symptoms, and type and duration of all therapeutic measures provided. If conservative management is not appropriate, the reason must be clearly documented. Conservative management must include a combination of strategies to reduce inflammation, alleviate pain, and correct underlying dysfunction, including physical therapy AND at least ONE complementary conservative treatment strategy (physical therapy rendered by a qualified provider, or a supervised home treatment program with initial active instruction by MD/DO/PT and documented compliance
• complementary = anti-inflammatory medications and analgesics, adjunctive medications, intra-articular corticosteroid injection(s), or activity modification / trial period of rest). Failure of conservative management requires ALL the following: Patient has completed a full course of conservative management (as defined above) for the current episode of care
• Worsening of or no significant improvement in signs and/or symptoms upon clinical reevaluation
• More invasive forms of therapy are being considered. Reporting symptom severity - significant pain and functional impairment refer to pain rated at least 3 out of 10 in intensity and associated with inability to perform ADLs and/or IADLs. Imaging reports obtained within the past 12 months describing the degree of cartilage damage: X-ray report or provider interpretation of x-rays that utilizes or can be correlated with the Kellgren-Lawrence grading system of osteoarthritis, and/or MRI report from a radiologist that utilizes or can be correlated with the modified Outerbridge or similar classification system. General Recommendations (strongly recommended, not required): tobacco/nicotine abstinence for at least 6 weeks prior to surgery
• hemoglobin A1C of 8% or less prior to any joint replacement surgery
• BMI equal to or greater than 40 attempt weight reduction prior to surgery.

Situations to verify before submitting

Blue Cross NC may not cover Total Shoulder Arthroplasty in these situations. Verify against the current policy rather than assuming a denial:

• {"text":"\"All procedures listed in this guideline are contraindicated when ANY of the following conditions are present: Active infection of the joint; Active systemic bacteremia; Active skin infection or open wound at the surgical site; Rapidly progressive neurologic disease; Intra-articular corticosteroid injection within the past 6 weeks in the joint being replaced.\" Exclusions: \"Shoulder arthroplasty under conditions which would result in excessive stress on the implant including, but not limited to, Charcot joint and paralytic conditions of the shoulder; Shoulder resurfacing, including total, hemi, or partial resurfacing.\"","source":"https://guidelines.carelonmedicalbenefitsmanagement.com/joint-surgery-2025-11-15/"}

How to submit

• Method: Prior authorization is delegated to Carelon Medical Benefits Management for spine surgery, joint surgery, interventional pain management, and small joint surgery (Commercial Fully Insured since 2023-10-01; ASO groups only if the group elected the program, effective 2025-01-01 - verify by member ID on the Carelon portal or via the number on the member ID card). Submit through the Carelon Provider Portal via Blue e (24/7, real-time against Carelon clinical guidelines) or by phone at 866-455-8414, Monday-Friday 8 a.m.-6 p.m. ET. Applies in both outpatient and inpatient admission settings. Since 2025-07-01 (Fully Insured only; excludes Medicare Advantage, DSNP, EGWP, FEP and ASO), a request for a hospital-based OUTPATIENT setting for interventional pain or joint-arthroscopy/small-joint procedures gets an additional site-of-care review.
• Portal: Carelon Provider Portal (via Blue e)
• Typical turnaround: about 3 days

Sources & verification

• BindingSource - Carelon Clinical Appropriateness Guidelines: Joint Surgery (Joint Surgery 2025-11-15) · effective 2025-11-15.View
• BindingSource - Blue Cross NC Musculoskeletal Program and Interventional Pain Management effective October 1, 2023 (Carelon delegation) (Provider news 2023-10-01) · effective 2023-10-01.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 2026-09-20.

Frequently asked questions

Other Blue Cross NC prior authorization requirements

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