Carelon Shoulder Arthroscopy Rotator Cuff Repair prior authorization requirements (2026)
What Carelon generally requires to approve Shoulder Arthroscopy Rotator Cuff Repair (CPT 29827), for Commercial plans. Yes. Carelon generally requires prior authorization for Shoulder Arthroscopy Rotator Cuff Repair (CPT 29827).
Medical-necessity criteria Carelon generally applies
Patient must meet ALL: (1) MRI confirming rotator cuff tear — full-thickness tear of supraspinatus, infraspinatus, subscapularis, or teres minor; OR partial-thickness tear ≥50% of tendon thickness; (2) Duration of shoulder pain and dysfunction ≥6 weeks; (3) Failure of structured conservative care: formal PT ≥6 weeks with rotator cuff-specific protocol (strengthening, ROM, neuromuscular control), plus NSAID trial; (4) Documented functional limitations: limited active elevation/abduction, strength deficit on manual muscle testing, or inability to perform occupational tasks at or above shoulder height; (5) Confirmed absence of adhesive capsulitis as primary diagnosis (if present, manipulate under anesthesia criteria apply instead)
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 Carelon policy.
Commonly required documentation
- MRI report specifying tear type (partial vs. full), involved tendon(s), tear size in cm, and degree of retraction/muscle atrophy
- PT records with ≥6 weeks of rotator cuff protocol
- documented ROM measurements (active forward flexion, external/internal rotation)
- shoulder functional scores (QuickDASH, ASES, or PENN)
- manual muscle testing strength grades
- surgeon evaluation with operative plan
- ultrasound acceptable if MRI contraindicated
How to submit
- Portal: Carelon Provider Portal
- Typical turnaround: about 3 days
Source
Tear size and retraction on MRI are key — large retracted tears with muscle atrophy may have urgent review pathway. Massively retracted tears with fatty infiltration (Goutallier Grade 3–4) require additional justification for repair attempt. Document occupational demands and sport if applicable.
Frequently asked questions
Does Carelon require prior authorization for Shoulder Arthroscopy Rotator Cuff Repair?
Yes. Carelon generally requires prior authorization for Shoulder Arthroscopy Rotator Cuff Repair (CPT 29827).
What does Carelon require to approve Shoulder Arthroscopy Rotator Cuff Repair?
Patient must meet ALL: (1) MRI confirming rotator cuff tear — full-thickness tear of supraspinatus, infraspinatus, subscapularis, or teres minor; OR partial-thickness tear ≥50% of tendon thickness; (2) Duration of shoulder pain and dysfunction ≥6 weeks; (3) Failure of structured conservative care: formal PT ≥6 weeks with rotator cuff-specific protocol (strengthening, ROM, neuromuscular control), p… Always confirm against the current Carelon policy.
How long does a Carelon prior authorization take?
Carelon 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 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.