Clover Health Knee Arthroscopy prior authorization requirements (2026)
What Clover Health generally requires to approve Knee Arthroscopy (CPT 29875, 29876, 29877, 29879), for medicare_advantage plans. Yes. Clover Health generally requires prior authorization for Knee Arthroscopy (CPT 29875, 29876, 29877, 29879).
Medical-necessity criteria Clover Health generally applies
Prior authorization required; Clover delegates joint/MSK surgery utilization management to eviCore. No Medicare NCD/LCD for knee arthroscopy, so eviCore MSK clinical guidelines govern (expect documented conservative care and imaging).
Diagnoses that commonly support medical necessity
ICD-10-CM diagnoses frequently associated with medical necessity for Knee Arthroscopy. Confirm the covered diagnosis list against the current Clover Health policy.
How to submit
- Method: eviCore portal
- Portal: eviCore (by Evernorth)
Sources & verification
- BindingSource — Clover Health — Interventional Pain, Spine and Joint Surgeries (eviCore).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 2026-06-25.
Frequently asked questions
Does Clover Health require prior authorization for Knee Arthroscopy?
Yes. Clover Health generally requires prior authorization for Knee Arthroscopy (CPT 29875, 29876, 29877, 29879).
What does Clover Health require to approve Knee Arthroscopy?
Prior authorization required; Clover delegates joint/MSK surgery utilization management to eviCore. No Medicare NCD/LCD for knee arthroscopy, so eviCore MSK clinical guidelines govern (expect documented conservative care and imaging). Always confirm against the current Clover Health policy.
How long does a Clover Health prior authorization take?
Turnaround varies by plan and submission method. Check the Clover Health portal for current timeframes.
Submitting Knee Arthroscopy to Clover Health?
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.