eviCore Total Shoulder Arthroplasty prior authorization requirements (2026)
What eviCore generally requires to approve Total Shoulder Arthroplasty (CPT 23472), for Commercial plans. Yes. eviCore generally requires prior authorization for Total Shoulder Arthroplasty (CPT 23472).
Medical-necessity criteria eviCore generally applies
Patient must meet ALL: (1) Severe glenohumeral arthritis confirmed on X-ray (significant joint space loss, osteophytes, subchondral sclerosis) — avascular necrosis, primary OA, or post-traumatic arthritis; (2) Failure of ≥3 months conservative care: PT, NSAIDs, and intra-articular corticosteroid injections (at least 1 injection unless contraindicated); (3) Severe functional impairment (ASES score <50 or VAS ≥7/10, limited passive ROM); (4) For anatomic TSA: intact or repairable rotator cuff required — MRI to confirm cuff integrity; (5) Intact deltoid function confirmed on examination
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 eviCore policy.
Commonly required documentation
- AP, lateral, and axillary shoulder X-rays demonstrating joint destruction
- MRI confirming rotator cuff status (critical for type selection — anatomic vs. reverse)
- conservative care records
- ASES or DASH outcome scores
- surgeon evaluation documenting glenohumeral arthritis grade and cuff status
- medical clearance if applicable
How to submit
- Portal: eviCore Connect
- Typical turnaround: about 3 days
Source
Specify anatomic vs. reverse TSA in PA — different criteria apply. Reverse TSA additionally requires documentation of massive irreparable cuff tear or cuff tear arthropathy with intact deltoid. Hemiarthroplasty for proximal humeral fractures may have expedited review.
Frequently asked questions
Does eviCore require prior authorization for Total Shoulder Arthroplasty?
Yes. eviCore generally requires prior authorization for Total Shoulder Arthroplasty (CPT 23472).
What does eviCore require to approve Total Shoulder Arthroplasty?
Patient must meet ALL: (1) Severe glenohumeral arthritis confirmed on X-ray (significant joint space loss, osteophytes, subchondral sclerosis) — avascular necrosis, primary OA, or post-traumatic arthritis; (2) Failure of ≥3 months conservative care: PT, NSAIDs, and intra-articular corticosteroid injections (at least 1 injection unless contraindicated); (3) Severe functional impairment (ASES score … Always confirm against the current eviCore policy.
How long does a eviCore prior authorization take?
eviCore typically decides Total Shoulder Arthroplasty requests in about 3 days. Timeframes vary; check the payer portal.
Submitting Total Shoulder Arthroplasty 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.