eviCore Shoulder Arthroplasty Including Revision Procedures prior authorization requirements (2026)
What eviCore generally requires to approve Shoulder Arthroplasty Including Revision Procedures (CPT 23470, 23472, 23473, 23474), for Commercial plans. Yes. eviCore generally requires prior authorization for Shoulder Arthroplasty Including Revision Procedures (CPT 23470, 23472, 23473, 23474).
Medical-necessity criteria eviCore generally applies
Patient must meet ALL: (1) Severe glenohumeral arthritis (primary OA, rotator cuff arthropathy, post-traumatic, or AVN) confirmed on X-ray with significant joint space loss; (2) Failure of ≥3 months conservative care: PT, NSAIDs, and intra-articular corticosteroid injections; (3) Significant pain and functional limitation (ASES score <50 or VAS ≥7/10); (4) For reverse total shoulder: massive rotator cuff tear or rotator cuff tear arthropathy — additional imaging confirming cuff status required; (5) Surgical risk assessment completed
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 eviCore policy.
Commonly required documentation
- AP, lateral, and axillary X-rays of shoulder showing joint destruction
- MRI or ultrasound if rotator cuff status relevant (especially for reverse TSA)
- conservative care records
- ASES or DASH functional scores
- surgeon evaluation
- medical clearance if applicable
How to submit
- Portal: eviCore Connect
- Typical turnaround: about 3 days
Source
Distinguish anatomic vs. reverse TSA in PA request — reverse TSA criteria include intact deltoid function and massive irreparable cuff tear. Revision shoulder arthroplasty requires prior operative reports and implant records.
Frequently asked questions
Does eviCore require prior authorization for Shoulder Arthroplasty Including Revision Procedures?
Yes. eviCore generally requires prior authorization for Shoulder Arthroplasty Including Revision Procedures (CPT 23470, 23472, 23473, 23474).
What does eviCore require to approve Shoulder Arthroplasty Including Revision Procedures?
Patient must meet ALL: (1) Severe glenohumeral arthritis (primary OA, rotator cuff arthropathy, post-traumatic, or AVN) confirmed on X-ray with significant joint space loss; (2) Failure of ≥3 months conservative care: PT, NSAIDs, and intra-articular corticosteroid injections; (3) Significant pain and functional limitation (ASES score <50 or VAS ≥7/10); (4) For reverse total shoulder: massive rotat… Always confirm against the current eviCore policy.
How long does a eviCore prior authorization take?
eviCore typically decides Shoulder Arthroplasty Including Revision Procedures requests in about 3 days. Timeframes vary; check the payer portal.
Submitting Shoulder Arthroplasty Including Revision Procedures to eviCore?
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.