QualCare Shoulder Arthroscopy Rotator Cuff Repair prior authorization requirements (2026)
What QualCare generally requires to approve Shoulder Arthroscopy Rotator Cuff Repair (CPT 29827), for commercial plans. Yes. QualCare generally requires prior authorization for Shoulder Arthroscopy Rotator Cuff Repair (CPT 29827).
Medical-necessity criteria QualCare generally applies
Prior authorization via eviCore (Cigna MSK program). Rotator cuff repair medically necessary when imaging shows a Grade 2-3 partial-thickness (Ellman) or full-thickness (Cofield) tear, exam shows ROM/strength loss plus a positive orthopedic test, function-limiting pain, and failure of provider-directed non-surgical management for at least 3 months — except an acute traumatic full-thickness tear (no fatty infiltration/atrophy) does not require the 3-month trial. Governed by eviCore CMM-315.
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 QualCare policy.
How to submit
- Method: eviCore portal
- Portal: eviCore by Evernorth (Cigna MSK/Spine)
Sources & verification
- BindingSource — Cigna CMM-315 Shoulder Surgery — Arthroscopic and Open Procedures (CMM-315) · effective 2025-07-01.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 2026-06-26.
Frequently asked questions
Does QualCare require prior authorization for Shoulder Arthroscopy Rotator Cuff Repair?
Yes. QualCare generally requires prior authorization for Shoulder Arthroscopy Rotator Cuff Repair (CPT 29827).
What does QualCare require to approve Shoulder Arthroscopy Rotator Cuff Repair?
Prior authorization via eviCore (Cigna MSK program). Rotator cuff repair medically necessary when imaging shows a Grade 2-3 partial-thickness (Ellman) or full-thickness (Cofield) tear, exam shows ROM/strength loss plus a positive orthopedic test, function-limiting pain, and failure of provider-directed non-surgical management for at least 3 months — except an acute traumatic full-thickness tear (n… Always confirm against the current QualCare policy.
How long does a QualCare prior authorization take?
Turnaround varies by plan and submission method. Check the QualCare portal for current timeframes.
Submitting Shoulder Arthroscopy Rotator Cuff Repair to QualCare?
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.