Carelon Total Shoulder Arthroplasty prior authorization requirements (2026)
What Carelon generally requires to approve Total Shoulder Arthroplasty (CPT 23472), for Commercial plans. Yes. Carelon generally requires prior authorization for Total Shoulder Arthroplasty (CPT 23472).
Medical-necessity criteria Carelon generally applies
Patient must meet ALL: (1) Severe glenohumeral arthritis confirmed on X-ray (significant joint space narrowing, osteophyte formation, or humeral head flattening from AVN); (2) Conservative care failure ≥3 months: PT focused on rotator cuff and periscapular strengthening, NSAIDs, and ≥1 corticosteroid injection; (3) ASES score <50 AND forward elevation <120° active, documenting severe functional limitation; (4) Anatomic TSA: MRI confirming intact or reparable rotator cuff, concentric glenoid wear pattern; Reverse TSA: massive irreparable rotator cuff tear (Goutallier Grade 3–4 fatty infiltration or complete tear with retraction >3 cm), rotator cuff arthropathy, or complex revision case — intact deltoid mandatory; (5) Bone stock adequate for implant fixation on CT if severe glenoid wear
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 Carelon policy.
Commonly required documentation
- True AP glenoid, axillary, and scapular Y X-rays documenting arthritis
- MRI with cuff assessment (Goutallier grade, tear size, retraction)
- ASES score and active forward elevation ROM measurement
- conservative care records
- if reverse TSA, document deltoid function (axillary nerve intact)
- CT of glenoid if significant bone loss suspected
- surgeon evaluation with implant type selection
How to submit
- Portal: Carelon Provider Portal
- Typical turnaround: about 3 days
Source
Carelon requires ASES <50 AND documented ROM limitation — collect both at surgical visit. Reverse vs anatomic TSA must be clearly specified with rationale. Glenoid bone loss (type B2, C, D) may require CT for implant planning and should be included in PA request.
Frequently asked questions
Does Carelon require prior authorization for Total Shoulder Arthroplasty?
Yes. Carelon generally requires prior authorization for Total Shoulder Arthroplasty (CPT 23472).
What does Carelon require to approve Total Shoulder Arthroplasty?
Patient must meet ALL: (1) Severe glenohumeral arthritis confirmed on X-ray (significant joint space narrowing, osteophyte formation, or humeral head flattening from AVN); (2) Conservative care failure ≥3 months: PT focused on rotator cuff and periscapular strengthening, NSAIDs, and ≥1 corticosteroid injection; (3) ASES score <50 AND forward elevation <120° active, documenting severe functional li… Always confirm against the current Carelon policy.
How long does a Carelon prior authorization take?
Carelon typically decides Total Shoulder Arthroplasty requests in about 3 days. Timeframes vary; check the payer portal.
Submitting Total Shoulder Arthroplasty 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.