Horizon BCBS NJ Shoulder Arthroplasty Including Revision Procedures prior authorization requirements (2026)
What Horizon BCBS NJ generally requires to approve Shoulder Arthroplasty Including Revision Procedures (CPT 23470, 23472, 23473, 23474), for PPO plans. Yes. Horizon BCBS NJ generally requires prior authorization for Shoulder Arthroplasty Including Revision Procedures (CPT 23470, 23472, 23473, 23474).
Medical-necessity criteria Horizon BCBS NJ generally applies
Prior authorization required; managed by TurningPoint Healthcare Solutions under the Horizon Surgical & Implantable Device Management Program (policy OR-1023, Shoulder Replacement: Total, Reverse, Revision, Hemi). Binding TurningPoint OR-1023 text is portal-only; the medical-necessity standard below reflects the evidence-based Carelon Joint Surgery guideline (MSK02-1124.1, eff. 11/17/2024). Total/anatomic shoulder arthroplasty (23472): advanced glenohumeral joint disease (osteoarthritis, RA, avascular necrosis, post-traumatic arthritis) with limited ROM or crepitus on exam, pain and loss of function of at least 6 months interfering with daily activities, radiographs showing marked joint-space narrowing plus one or more additional degenerative findings, and failure of at least 6 weeks of conservative management (physical therapy plus at least one of anti-inflammatories/analgesics, intra-articular corticosteroid injection, or activity modification) unless radiographs show Kellgren-Lawrence grade 4. Hemiarthroplasty (23470): TSA criteria plus a cuff/glenoid-specific indication (humeral-head osteonecrosis without glenoid involvement, rotator cuff tear arthropathy, inadequate glenoid bone stock, or osteoarthritis with irreparable cuff). Reverse total (reported under 23472): irreparable/deficient rotator cuff (cuff tear arthropathy, pseudoparalysis), failed prior hemi/TSA, or an unreconstructable fracture. Revision (23473/23474): aseptic component loosening, component fracture, periprosthetic-infection reconstruction, instability, or superior humeral migration confirmed on imaging. Also requires an intact deltoid and a joint structurally suited to the implant. Verify binding criteria in the TurningPoint portal for the member''s plan.
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 Horizon BCBS NJ policy.
Related procedure codes
Codes often billed alongside Shoulder Arthroplasty Including Revision Procedures: 23470, 23472, 23473, 23474. Verify the correct codes for your documentation.
Situations to verify before submitting
Horizon BCBS NJ may not cover Shoulder Arthroplasty Including Revision Procedures in these situations. Verify against the current policy rather than assuming a denial:
- Active joint infection, systemic bacteremia, or active skin infection/open wound at the surgical site
- Intra-articular corticosteroid injection in the joint within the past 6 weeks
- Rapidly progressive neurologic disease
- Shoulder resurfacing arthroplasty and arthroplasty for Charcot joint or paralytic shoulder conditions (non-covered)
How to submit
- Method: portal
- Portal: TurningPoint Healthcare Solutions Web Portal
Source
PA managed by TurningPoint (Horizon Surgical & Implantable Device Management Program, live 7/1/2022), NOT AIM/Carelon. Shoulder arthroplasty confirmed in TurningPoint scope, mapped to policy OR-1023 (Total/Reverse/Revision/Hemi). Criteria framed from the public Carelon Joint Surgery guideline MSK02-1124.1 (eff 11/17/2024, ) as the evidence-based standard; binding OR-1023 text is portal-only (myturningpoint-healthcare.com). CPT note: reverse TSA has no distinct code and is reported under 23472. PA applicability varies by Horizon product (commercial fully-insured vs self-funded ASO vs FEP); verify per member. [SPOT-CHECK] View the source policy. Last verified 2026-06-18.
Frequently asked questions
Does Horizon BCBS NJ require prior authorization for Shoulder Arthroplasty Including Revision Procedures?
Yes. Horizon BCBS NJ generally requires prior authorization for Shoulder Arthroplasty Including Revision Procedures (CPT 23470, 23472, 23473, 23474).
What does Horizon BCBS NJ require to approve Shoulder Arthroplasty Including Revision Procedures?
Prior authorization required; managed by TurningPoint Healthcare Solutions under the Horizon Surgical & Implantable Device Management Program (policy OR-1023, Shoulder Replacement: Total, Reverse, Revision, Hemi). Binding TurningPoint OR-1023 text is portal-only; the medical-necessity standard below reflects the evidence-based Carelon Joint Surgery guideline (MSK02-1124.1, eff. 11/17/2024). Total/… Always confirm against the current Horizon BCBS NJ policy.
How long does a Horizon BCBS NJ prior authorization take?
Turnaround varies by plan and submission method. Check the Horizon BCBS NJ portal for current timeframes.
Submitting Shoulder Arthroplasty Including Revision Procedures to Horizon BCBS NJ?
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.