Horizon BCBS NJ Total Shoulder Arthroplasty prior authorization requirements (2026)
What Horizon BCBS NJ generally requires to approve Total Shoulder Arthroplasty (CPT 23472), for PPO, EPO, BlueCard, FEP plans. Yes. Horizon BCBS NJ generally requires prior authorization for Total Shoulder Arthroplasty (CPT 23472).
Medical-necessity criteria Horizon BCBS NJ generally applies
Per FEP Medical Policy: radiographic confirmation of advanced glenohumeral OA, avascular necrosis, or rotator cuff arthropathy. Failed ≥6 weeks (typically 3+ months documented) conservative care including NSAIDs, supervised PT, activity modification, and intra-articular corticosteroid injection. Functional impairment with ADL limitations and pain refractory to non-operative measures. Intact deltoid; adequate bone stock on imaging.
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 Horizon BCBS NJ policy.
Commonly required documentation
- H&P, radiographs and advanced imaging reports, complete conservative treatment log with dates/durations, supervised PT notes, injection records, medication trial documentation, surgical plan, FEP member ID
How to submit
- Method: portal
- Portal: FEP Provider Portal
- Typical turnaround: about 7 days
Sources & verification
- UnverifiedSource.View
Binding = the payer's own policy. Proxy = a public, evidence-based clinical guideline the payer mirrors. Portal-only = the binding criteria are confirmed in the administrator's portal. Always confirm against the payer for the member's specific plan. Last verified 2026-05-18.
Frequently asked questions
Does Horizon BCBS NJ require prior authorization for Total Shoulder Arthroplasty?
Yes. Horizon BCBS NJ generally requires prior authorization for Total Shoulder Arthroplasty (CPT 23472).
What does Horizon BCBS NJ require to approve Total Shoulder Arthroplasty?
Per FEP Medical Policy: radiographic confirmation of advanced glenohumeral OA, avascular necrosis, or rotator cuff arthropathy. Failed ≥6 weeks (typically 3+ months documented) conservative care including NSAIDs, supervised PT, activity modification, and intra-articular corticosteroid injection. Functional impairment with ADL limitations and pain refractory to non-operative measures. Intact deltoi… Always confirm against the current Horizon BCBS NJ policy.
How long does a Horizon BCBS NJ prior authorization take?
Horizon BCBS NJ typically decides Total Shoulder Arthroplasty requests in about 7 days. Timeframes vary; check the payer portal.
Submitting Total Shoulder Arthroplasty 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.