Oscar Health Shoulder Arthroscopy Rotator Cuff Repair prior authorization requirements (2026)
What Oscar Health generally requires to approve Shoulder Arthroscopy Rotator Cuff Repair (CPT 29827), for commercial plans. Yes. Oscar Health generally requires prior authorization for Shoulder Arthroscopy Rotator Cuff Repair (CPT 29827).
Medical-necessity criteria Oscar Health generally applies
Prior authorization required via eviCore (CMM-315 Shoulder Surgery). Diagnostic arthroscopy: at least 6 months of function-limiting pain, at least 3 months of failed provider-directed non-surgical management, abnormal exam vs. contralateral, inconclusive MRI/CT.
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 Oscar Health policy.
How to submit
- Method: eviCore portal
- Portal: eviCore (by Evernorth)
Sources & verification
- BindingSource — Oscar — eviCore Musculoskeletal/Spine/Pain program.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 2026-06-25.
Frequently asked questions
Does Oscar Health require prior authorization for Shoulder Arthroscopy Rotator Cuff Repair?
Yes. Oscar Health generally requires prior authorization for Shoulder Arthroscopy Rotator Cuff Repair (CPT 29827).
What does Oscar Health require to approve Shoulder Arthroscopy Rotator Cuff Repair?
Prior authorization required via eviCore (CMM-315 Shoulder Surgery). Diagnostic arthroscopy: at least 6 months of function-limiting pain, at least 3 months of failed provider-directed non-surgical management, abnormal exam vs. contralateral, inconclusive MRI/CT. Always confirm against the current Oscar Health policy.
How long does a Oscar Health prior authorization take?
Turnaround varies by plan and submission method. Check the Oscar Health portal for current timeframes.
Submitting Shoulder Arthroscopy Rotator Cuff Repair to Oscar Health?
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.