Cigna Total Shoulder Arthroplasty prior authorization requirements (2026)
What Cigna generally requires to approve Total Shoulder Arthroplasty (CPT 23472), for PPO, HMO plans. Yes. Cigna generally requires prior authorization for Total Shoulder Arthroplasty (CPT 23472).
Medical-necessity criteria Cigna generally applies
Per Cigna CCP 0026: Symptomatic glenohumeral OA, RA, AVN, or post-traumatic arthritis with radiographic confirmation (joint space narrowing, osteophytes, subchondral changes). Must document completed 6-12 weeks supervised PT, NSAID trial, and intra-articular injection trial where appropriate. Persistent pain and ADL impairment despite conservative measures. In-network surgeon/facility required.
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 Cigna policy.
Commonly required documentation
- PCP referral, H&P, orthopedic consult, shoulder imaging reports (XR/MRI/CT), complete PT records with dates/visits/outcomes, medication trial documentation, injection history, functional scores (ASES/DASH), surgical plan, in-network facility confirmation
How to submit
- Method: portal
- Portal: Cigna for Health Care Professionals
- Typical turnaround: about 5 days
Source
PCP referral required. Strict in-network only; OON not covered except emergencies. HMO reviewers strictly enforce full conservative care documentation. Last verified 2026-05-18.
Frequently asked questions
Does Cigna require prior authorization for Total Shoulder Arthroplasty?
Yes. Cigna generally requires prior authorization for Total Shoulder Arthroplasty (CPT 23472).
What does Cigna require to approve Total Shoulder Arthroplasty?
Per Cigna CCP 0026: Symptomatic glenohumeral OA, RA, AVN, or post-traumatic arthritis with radiographic confirmation (joint space narrowing, osteophytes, subchondral changes). Must document completed 6-12 weeks supervised PT, NSAID trial, and intra-articular injection trial where appropriate. Persistent pain and ADL impairment despite conservative measures. In-network surgeon/facility required. Always confirm against the current Cigna policy.
How long does a Cigna prior authorization take?
Cigna typically decides Total Shoulder Arthroplasty requests in about 5 days. Timeframes vary; check the payer portal.
Submitting Total Shoulder Arthroplasty to Cigna?
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.