Humana Total Shoulder Arthroplasty prior authorization requirements (2026)
What Humana generally requires to approve Total Shoulder Arthroplasty (CPT 23472), for Commercial plans. Yes. Humana generally requires prior authorization for Total Shoulder Arthroplasty (CPT 23472).
Medical-necessity criteria Humana generally applies
(1) Severe glenohumeral arthritis on X-ray (OA, AVN, post-traumatic, cuff tear arthropathy); (2) Conservative care failure ≥3 months; (3) ASES <50 AND active forward elevation <120°; (4) Anatomic TSA: intact/reparable cuff on MRI; Reverse TSA: massive irreparable cuff tear with intact deltoid; (5) Bone stock assessment if significant glenoid wear
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 Humana policy.
Commonly required documentation
- True AP glenoid and axillary X-rays
- MRI for cuff status
- ASES and elevation ROM
- conservative care records
- surgeon evaluation with implant type
How to submit
- Portal: Humana Provider Portal / Availity
- Typical turnaround: about 3 days
Source
Collect ASES and active elevation measurement at surgical visit. Medicare Advantage: include post-op rehab plan in submission.
Frequently asked questions
Does Humana require prior authorization for Total Shoulder Arthroplasty?
Yes. Humana generally requires prior authorization for Total Shoulder Arthroplasty (CPT 23472).
What does Humana require to approve Total Shoulder Arthroplasty?
(1) Severe glenohumeral arthritis on X-ray (OA, AVN, post-traumatic, cuff tear arthropathy); (2) Conservative care failure ≥3 months; (3) ASES <50 AND active forward elevation <120°; (4) Anatomic TSA: intact/reparable cuff on MRI; Reverse TSA: massive irreparable cuff tear with intact deltoid; (5) Bone stock assessment if significant glenoid wear Always confirm against the current Humana policy.
How long does a Humana prior authorization take?
Humana typically decides Total Shoulder Arthroplasty requests in about 3 days. Timeframes vary; check the payer portal.
Submitting Total Shoulder Arthroplasty 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.