Medicare (CMS LCD/NCD) Total Shoulder Arthroplasty prior authorization requirements (2026)

Medical-necessity criteria Medicare (CMS LCD/NCD) generally applies

Palmetto GBA LCD L39956 - Total Shoulder Arthroplasty (revision effective 03/27/2025). "Coverage Indications, Limitations, and/or Medical Necessity" section, VERBATIM from the CMS Medicare Coverage Database API on 2026-09-20 (HTML converted to text; nothing paraphrased): Indications of Coverage Total shoulder arthroplasty (TSA) is reasonable and necessary for each of the following conditions: Degenerative glenohumeral joint disease including osteoarthritis (OA), OR post-traumatic arthritis, OR rheumatoid arthritis (RA), OR osteonecrosis, OR arthropathy with rotator cuff deficit when all the following are present: Documented radiographic evidence of the diagnosis (e.g., irregular joint surfaces, subchondral cysts, glenoid flattening or sclerosis, periarticular osteophytes, joint subluxation, joint space narrowing, or avascular necrosis); AND Documentation of moderate-to-severe chronic pain OR chronic functional disability for a minimum of 12 weeks; AND Documentation of at least 12 weeks of unsuccessful conservative therapy. (If conservative therapy is not appropriate, the medical record must clearly document why such approach is not reasonable.) 1 Treatment of acute proximal humerus fractures (PHFs) not amenable to conservative therapy or internal fixation Treatment of nonunion or malunion PHFs with radiographic evidence Reconstruction following tumor resection of the glenohumeral joint, proximal humerus, or adjacent tissue Massive irreparable rotator cuff tears (MIRCTs) when all the following are present: Evidence of massive rotator cuff tear (MRCT) by magnetic resonance imaging (MRI) or arthroscopy (e.g., tear size greater than 5 cm in an anterior-posterior or medial-lateral orientation, OR tears of 2 or more tendons, OR retraction of the tendon to the glenoid rim with greater than 2/3 of the greater tuberosity exposed on imaging in the sagittal plane) 2 Pseudo-paralysis Documentation of at least 12 weeks of unsuccessful conservative therapy including 12 weeks of supervised physical therapy (PT). (If conservative therapy is not appropriate, the medical record must clearly document why such approach is not reasonable.) Reverse total shoulder arthroplasty (RTSA) following failed anatomic total shoulder arthroplasty (aTSA) or failed hemiarthroplasty (HA) NOTE: To document unsuccessful conservative therapy, a pain or disability assessment must be performed and documented at baseline and after therapeutic intervention using the same scale for each assessment. The scales used for measurement of pain or disability must be documented in the medical record. Acceptable scales include but are not limited to: verbal rating scales, Numerical Rating Scale (NRS), Visual Analog Scale (VAS) for pain assessment, Disabilities of the Arm, Shoulder and Hand (DASH), Shoulder Pain and Disability Index (SPADI), American Shoulder and Elbow Surgeon score (ASES), Simple Shoulder Test (SST), Constant-Murley score, and Western Ontario Rotator Cuff Index (WORC). Limitations of Coverage Provider Qualifications The Medicare Program Integrity Manual states services will be considered medically reasonable and necessary only if performed by appropriately trained providers. Patient safety and quality-of-care mandate that healthcare professionals who perform shoulder arthroplasty are appropriately trained and/or credentialed by a formal residency/fellowship program, and/or are certified by either an accredited and nationally recognized organization, or by a post-graduate training course accredited by an established national accrediting body or accredited professional training program whose core curriculum includes the performance and management of the procedures addressed in this LCD. Credentialing and privileges are required for procedures performed in inpatient and outpatient settings. Definitions Conservative therapy: nonoperative treatment that may include 1 or more of the following: Anti-inflammatory medications or analgesics Flexibility and muscle strengthening exercises A trial of supervised PT Corticosteroid injections Pseudo-paralysis: MRCT with active elevation less than 90 degrees against gravity 3,4 Total shoulder arthroplasty (also known as total shoulder replacement): a surgical procedure that replaces both the glenoid and proximal humerus with prosthetic parts. This includes both aTSA and RTSA. [NEEDS CLINICAL SPOT-CHECK]

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 Medicare (CMS LCD/NCD) policy.

How to submit

• Method: Traditional Medicare: no prior authorization in the office or ASC setting - bill Part B with documentation on file. If performed in a HOSPITAL OUTPATIENT DEPARTMENT, check the CMS OPD prior-authorization list for the specific code before the date of service. Medicare Advantage plans (Humana, UHC, Aetna, Blue Medicare) require their own PA but must apply this LCD's criteria under 42 CFR 422.101(b).

Sources & verification

• BindingSource - LCD: Total Shoulder Arthroplasty (L39956) · effective 2025-03-27.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 2026-09-20.

Frequently asked questions

Other Medicare (CMS LCD/NCD) prior authorization requirements

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