Humana Shoulder Arthroplasty Including Revision Procedures prior authorization requirements (2026)
What Humana generally requires to approve Shoulder Arthroplasty Including Revision Procedures (CPT 23470, 23472, 23473, 23474), for Commercial plans. Yes. Humana generally requires prior authorization for Shoulder Arthroplasty Including Revision Procedures (CPT 23470, 23472, 23473, 23474).
Medical-necessity criteria Humana generally applies
(1) Severe glenohumeral arthritis on X-ray with significant joint space loss; (2) Conservative care failure ≥3 months (PT, NSAIDs, ≥1 injection); (3) ASES <50 or VAS ≥7/10; (4) MRI/ultrasound for rotator cuff assessment (anatomic vs. reverse selection); (5) Intact deltoid for reverse TSA
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 Humana policy.
Commonly required documentation
- Shoulder X-rays
- MRI or ultrasound
- ASES and DASH scores
- conservative care records
- surgeon evaluation with implant type rationale
How to submit
- Portal: Humana Provider Portal / Availity
- Typical turnaround: about 3 days
Source
Implant type (anatomic vs. reverse) must be specified. Medicare Advantage patients: documentation of functional goals required.
Frequently asked questions
Does Humana require prior authorization for Shoulder Arthroplasty Including Revision Procedures?
Yes. Humana generally requires prior authorization for Shoulder Arthroplasty Including Revision Procedures (CPT 23470, 23472, 23473, 23474).
What does Humana require to approve Shoulder Arthroplasty Including Revision Procedures?
(1) Severe glenohumeral arthritis on X-ray with significant joint space loss; (2) Conservative care failure ≥3 months (PT, NSAIDs, ≥1 injection); (3) ASES <50 or VAS ≥7/10; (4) MRI/ultrasound for rotator cuff assessment (anatomic vs. reverse selection); (5) Intact deltoid for reverse TSA Always confirm against the current Humana policy.
How long does a Humana prior authorization take?
Humana typically decides Shoulder Arthroplasty Including Revision Procedures requests in about 3 days. Timeframes vary; check the payer portal.
Submitting Shoulder Arthroplasty Including Revision Procedures to Humana?
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.