Sedgwick Shoulder Arthroscopy Rotator Cuff Repair prior authorization requirements (2026)
What Sedgwick generally requires to approve Shoulder Arthroscopy Rotator Cuff Repair (CPT 29827). Yes. Sedgwick generally requires prior authorization for Shoulder Arthroscopy Rotator Cuff Repair (CPT 29827).
Medical-necessity criteria Sedgwick generally applies
Sedgwick/ODG WC criteria: (1) Work-related causation from treating surgeon; (2) MRI confirming rotator cuff tear; (3) ODG-compliant PT (per ODG rotator cuff protocol duration); (4) NSAID trial; (5) NCM notified of surgical plan; (6) Employer/TPA authorization; (7) IME if causation disputed by employer; (8) RTW plan with shoulder restrictions
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 Sedgwick policy.
Commonly required documentation
- Causation narrative
- MRI
- PT records per ODG duration
- NCM notification documentation
- IME if applicable
- RTW plan with restrictions
- employer claim number
How to submit
- Portal: mySedgwick Provider Portal
- Typical turnaround: about 5 days
Source
Contact claim adjuster early — Sedgwick's NCMs facilitate surgical authorization process. Employers with high claim frequency may require second-opinion IME regardless of causation clarity. Causation of acute vs. degenerative RTC tear is key dispute point.
Frequently asked questions
Does Sedgwick require prior authorization for Shoulder Arthroscopy Rotator Cuff Repair?
Yes. Sedgwick generally requires prior authorization for Shoulder Arthroscopy Rotator Cuff Repair (CPT 29827).
What does Sedgwick require to approve Shoulder Arthroscopy Rotator Cuff Repair?
Sedgwick/ODG WC criteria: (1) Work-related causation from treating surgeon; (2) MRI confirming rotator cuff tear; (3) ODG-compliant PT (per ODG rotator cuff protocol duration); (4) NSAID trial; (5) NCM notified of surgical plan; (6) Employer/TPA authorization; (7) IME if causation disputed by employer; (8) RTW plan with shoulder restrictions Always confirm against the current Sedgwick policy.
How long does a Sedgwick prior authorization take?
Sedgwick typically decides Shoulder Arthroscopy Rotator Cuff Repair requests in about 5 days. Timeframes vary; check the payer portal.
Submitting Shoulder Arthroscopy Rotator Cuff Repair to Sedgwick?
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.