eviCore Shoulder Arthroscopy Rotator Cuff Repair prior authorization requirements (2026)
What eviCore generally requires to approve Shoulder Arthroscopy Rotator Cuff Repair (CPT 29827), for Commercial plans. Yes. eviCore generally requires prior authorization for Shoulder Arthroscopy Rotator Cuff Repair (CPT 29827).
Medical-necessity criteria eviCore generally applies
Patient must meet ALL: (1) MRI confirming rotator cuff tear — full-thickness tear OR partial-thickness tear involving ≥50% of tendon width at minimum; (2) Symptoms of ≥6 weeks duration with documented pain and functional deficit; (3) Failure of conservative treatment: formal PT ≥6 weeks focused on rotator cuff strengthening and scapular stabilization, plus NSAIDs or analgesics; (4) Documented functional deficit including limited active range of motion, weakness on rotator cuff testing, or inability to perform occupational/ADL tasks; (5) Cervical radiculopathy ruled out as primary cause of symptoms
Diagnoses that commonly support medical necessity
ICD-10-CM diagnoses frequently associated with medical necessity for Shoulder Arthroscopy Rotator Cuff Repair. Confirm the covered diagnosis list against the current eviCore policy.
Commonly required documentation
- MRI report confirming tear location, size, and depth
- PT records with visit dates and treatment focus
- documented ROM measurements (active and passive)
- shoulder functional outcome scores (ASES, DASH, or QuickDASH)
- surgeon evaluation note documenting strength testing and functional deficit
- imaging films or PACS access if requested
How to submit
- Portal: eviCore Connect
- Typical turnaround: about 3 days
Source
eviCore distinguishes between acute traumatic tears and degenerative tears — acute full-thickness tears may bypass conservative care requirement. Partial-thickness tears <50% typically require longer conservative care documentation. Peer-to-peer available.
Frequently asked questions
Does eviCore require prior authorization for Shoulder Arthroscopy Rotator Cuff Repair?
Yes. eviCore generally requires prior authorization for Shoulder Arthroscopy Rotator Cuff Repair (CPT 29827).
What does eviCore require to approve Shoulder Arthroscopy Rotator Cuff Repair?
Patient must meet ALL: (1) MRI confirming rotator cuff tear — full-thickness tear OR partial-thickness tear involving ≥50% of tendon width at minimum; (2) Symptoms of ≥6 weeks duration with documented pain and functional deficit; (3) Failure of conservative treatment: formal PT ≥6 weeks focused on rotator cuff strengthening and scapular stabilization, plus NSAIDs or analgesics; (4) Documented func… Always confirm against the current eviCore policy.
How long does a eviCore prior authorization take?
eviCore typically decides Shoulder Arthroscopy Rotator Cuff Repair requests in about 3 days. Timeframes vary; check the payer portal.
Submitting Shoulder Arthroscopy Rotator Cuff Repair 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.