Coventry Workers' Comp Shoulder Arthroplasty Including Revision Procedures prior authorization requirements (2026)
What Coventry Workers' Comp generally requires to approve Shoulder Arthroplasty Including Revision Procedures (CPT 23470, 23472, 23473, 23474). Yes. Coventry Workers' Comp generally requires prior authorization for Shoulder Arthroplasty Including Revision Procedures (CPT 23470, 23472, 23473, 23474).
Medical-necessity criteria Coventry Workers' Comp generally applies
WC: (1) Work-related causation for glenohumeral pathology — typically significant traumatic event or repetitive heavy overhead loading; (2) Severe shoulder arthritis or rotator cuff arthropathy on imaging; (3) Conservative care failure ≥3 months; (4) IME required — shoulder arthroplasty in WC almost universally requires IME; (5) RTW plan with permanent upper extremity restrictions; (6) MMI assessment
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 Coventry Workers' Comp policy.
Commonly required documentation
- Causation narrative
- shoulder X-rays and MRI
- conservative care records
- IME report
- RTW plan with permanent restrictions and MMI designation
- ASES scores
How to submit
- Portal: Coventry Connect
- Typical turnaround: about 7 days
Source
Shoulder arthroplasty in WC: IME is essentially mandatory. Long adjudication timelines are common. Ensure treating surgeon produces detailed causation analysis addressing pre-existing conditions. MMI designation often required before surgical authorization.
Frequently asked questions
Does Coventry Workers' Comp require prior authorization for Shoulder Arthroplasty Including Revision Procedures?
Yes. Coventry Workers' Comp generally requires prior authorization for Shoulder Arthroplasty Including Revision Procedures (CPT 23470, 23472, 23473, 23474).
What does Coventry Workers' Comp require to approve Shoulder Arthroplasty Including Revision Procedures?
WC: (1) Work-related causation for glenohumeral pathology — typically significant traumatic event or repetitive heavy overhead loading; (2) Severe shoulder arthritis or rotator cuff arthropathy on imaging; (3) Conservative care failure ≥3 months; (4) IME required — shoulder arthroplasty in WC almost universally requires IME; (5) RTW plan with permanent upper extremity restrictions; (6) MMI assessm… Always confirm against the current Coventry Workers' Comp policy.
How long does a Coventry Workers' Comp prior authorization take?
Coventry Workers' Comp typically decides Shoulder Arthroplasty Including Revision Procedures requests in about 7 days. Timeframes vary; check the payer portal.
Submitting Shoulder Arthroplasty Including Revision Procedures to Coventry Workers' Comp?
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.