Humana Shoulder Arthroscopy Rotator Cuff Repair prior authorization requirements (2026)
What Humana generally requires to approve Shoulder Arthroscopy Rotator Cuff Repair (CPT 29827), for Commercial plans. Yes. Humana generally requires prior authorization for Shoulder Arthroscopy Rotator Cuff Repair (CPT 29827).
Medical-necessity criteria Humana generally applies
Patient must meet ALL: (1) MRI confirming rotator cuff tear (full-thickness or partial ≥50% tendon width); (2) Symptoms ≥6 weeks with documented pain and functional deficit; (3) Failure of ≥6 weeks formal PT with rotator cuff protocol and NSAID trial; (4) Documented ROM limitation and weakness on exam; (5) Cohere Health pathway completed if plan-routed; (6) Acute traumatic full-thickness tears may bypass conservative care requirement with ER/urgent care documentation
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 Humana policy.
Commonly required documentation
- MRI report with tear characterization
- PT records ≥6 weeks
- shoulder functional scores (ASES, QuickDASH)
- ROM and strength measurements
- surgeon evaluation
- Cohere authorization if applicable
How to submit
- Portal: Humana Provider Portal / Availity
- Typical turnaround: about 3 days
Source
Cohere Health routing increasingly common on Humana commercial plans for MSK. For Medicare Advantage members: functional documentation requirements are stricter — include ADL limitations.
Frequently asked questions
Does Humana require prior authorization for Shoulder Arthroscopy Rotator Cuff Repair?
Yes. Humana generally requires prior authorization for Shoulder Arthroscopy Rotator Cuff Repair (CPT 29827).
What does Humana require to approve Shoulder Arthroscopy Rotator Cuff Repair?
Patient must meet ALL: (1) MRI confirming rotator cuff tear (full-thickness or partial ≥50% tendon width); (2) Symptoms ≥6 weeks with documented pain and functional deficit; (3) Failure of ≥6 weeks formal PT with rotator cuff protocol and NSAID trial; (4) Documented ROM limitation and weakness on exam; (5) Cohere Health pathway completed if plan-routed; (6) Acute traumatic full-thickness tears may… Always confirm against the current Humana policy.
How long does a Humana prior authorization take?
Humana typically decides Shoulder Arthroscopy Rotator Cuff Repair requests in about 3 days. Timeframes vary; check the payer portal.
Submitting Shoulder Arthroscopy Rotator Cuff Repair 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.