Carelon Shoulder Arthroplasty Including Revision Procedures prior authorization requirements (2026)
What Carelon generally requires to approve Shoulder Arthroplasty Including Revision Procedures (CPT 23470, 23472, 23473, 23474), for Commercial plans. Yes. Carelon generally requires prior authorization for Shoulder Arthroplasty Including Revision Procedures (CPT 23470, 23472, 23473, 23474).
Medical-necessity criteria Carelon generally applies
Patient must meet ALL: (1) Severe glenohumeral joint destruction on X-ray (primary OA, cuff tear arthropathy, AVN, or post-traumatic) with significant loss of joint space and architectural disruption; (2) Conservative care failure ≥3 months: PT, NSAIDs, and ≥1 corticosteroid injection with inadequate sustained relief; (3) ASES score <50 or DASH score >50 documenting functional impairment; (4) For anatomic TSA: intact or reparable rotator cuff on MRI or ultrasound; (5) For reverse TSA: massive irreparable rotator cuff tear OR rotator cuff tear arthropathy with pseudo-paralysis — intact deltoid function required; (6) Contralateral shoulder evaluated if bilateral disease
Diagnoses that commonly support medical necessity
ICD-10-CM diagnoses frequently associated with medical necessity for Shoulder Arthroplasty Including Revision Procedures. Confirm the covered diagnosis list against the current Carelon policy.
Commonly required documentation
- Shoulder X-rays (AP true glenoid view, axillary view) documenting arthritis grade
- MRI or ultrasound for rotator cuff evaluation (required for TSA type selection)
- conservative care records
- ASES and DASH scores
- surgeon evaluation with implant type selection rationale
- if reverse TSA, document deltoid function and irreparability of cuff
How to submit
- Portal: Carelon Provider Portal
- Typical turnaround: about 3 days
Source
ASES <50 is the functional threshold Carelon uses — collect it at surgical consultation. Implant type must be specified (anatomic vs. reverse) — criteria differ. Revision arthroplasty requires prior operative reports, explanted implant records, and infection workup if applicable.
Frequently asked questions
Does Carelon require prior authorization for Shoulder Arthroplasty Including Revision Procedures?
Yes. Carelon generally requires prior authorization for Shoulder Arthroplasty Including Revision Procedures (CPT 23470, 23472, 23473, 23474).
What does Carelon require to approve Shoulder Arthroplasty Including Revision Procedures?
Patient must meet ALL: (1) Severe glenohumeral joint destruction on X-ray (primary OA, cuff tear arthropathy, AVN, or post-traumatic) with significant loss of joint space and architectural disruption; (2) Conservative care failure ≥3 months: PT, NSAIDs, and ≥1 corticosteroid injection with inadequate sustained relief; (3) ASES score <50 or DASH score >50 documenting functional impairment; (4) For … Always confirm against the current Carelon policy.
How long does a Carelon prior authorization take?
Carelon typically decides Shoulder Arthroplasty Including Revision Procedures requests in about 3 days. Timeframes vary; check the payer portal.
Submitting Shoulder Arthroplasty Including Revision Procedures to Carelon?
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.