Horizon BCBS NJ Shoulder Arthroscopy Rotator Cuff Repair prior authorization requirements (2026)
What Horizon BCBS NJ generally requires to approve Shoulder Arthroscopy Rotator Cuff Repair (CPT 29827), for EPO, PPO, BlueCard, FEP plans. Yes. Horizon BCBS NJ generally requires prior authorization for Shoulder Arthroscopy Rotator Cuff Repair (CPT 29827).
Medical-necessity criteria Horizon BCBS NJ generally applies
Symptomatic full-thickness or high-grade partial-thickness rotator cuff tear confirmed by MRI or MR arthrogram. Documented failure of ≥6 weeks conservative therapy including NSAIDs, activity modification, and supervised PT. Persistent pain and functional limitation (weakness, loss of ROM, inability to perform ADLs/work). Acute traumatic full-thickness tears in active patients may bypass conservative trial.
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 Horizon BCBS NJ policy.
Commonly required documentation
- H&P, MRI/MR arthrogram report, PT notes documenting ≥6 weeks therapy, conservative treatment log, functional assessment, op plan, imaging interpretation, ICD-10 codes
How to submit
- Method: portal
- Portal: TurningPoint Healthcare Solutions (Horizon Surgical & Implantable Device Mgmt Program)
- Typical turnaround: about 5 days
Source
PA managed by AIM Specialty Health (Carelon). Submit via AIM ProviderPortal linked through Horizon. | Vendor correction (verified 2026-06-18): Horizon delegates surgical orthopedic + spine PA to TurningPoint Healthcare Solutions (1-833-436-4083), NOT AIM/Carelon (Carelon at Horizon handles imaging/cardiology/oncology/sleep/pain). Spine-surgery PA transitioned from eviCore to TurningPoint. Source: View the source policy. Last verified 2026-06-18.
Frequently asked questions
Does Horizon BCBS NJ require prior authorization for Shoulder Arthroscopy Rotator Cuff Repair?
Yes. Horizon BCBS NJ generally requires prior authorization for Shoulder Arthroscopy Rotator Cuff Repair (CPT 29827).
What does Horizon BCBS NJ require to approve Shoulder Arthroscopy Rotator Cuff Repair?
Symptomatic full-thickness or high-grade partial-thickness rotator cuff tear confirmed by MRI or MR arthrogram. Documented failure of ≥6 weeks conservative therapy including NSAIDs, activity modification, and supervised PT. Persistent pain and functional limitation (weakness, loss of ROM, inability to perform ADLs/work). Acute traumatic full-thickness tears in active patients may bypass conservati… Always confirm against the current Horizon BCBS NJ policy.
How long does a Horizon BCBS NJ prior authorization take?
Horizon BCBS NJ typically decides Shoulder Arthroscopy Rotator Cuff Repair requests in about 5 days. Timeframes vary; check the payer portal.
Submitting Shoulder Arthroscopy Rotator Cuff Repair 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.