UnitedHealthcare Total Shoulder Arthroplasty prior authorization requirements (2026)
What UnitedHealthcare generally requires to approve Total Shoulder Arthroplasty (CPT 23472), for Commercial plans. Yes. UnitedHealthcare generally requires prior authorization for Total Shoulder Arthroplasty (CPT 23472).
Medical-necessity criteria UnitedHealthcare generally applies
UnitedHealthcare reviews total shoulder replacement against InterQual CP: Procedures (Joint Replacement, Shoulder), policy 2026T0556FF (Surgery of the Shoulder). Proven and medically necessary in certain circumstances; specific thresholds (documented glenohumeral osteoarthritis or cuff-tear arthropathy, failed non-operative care) are adjudicated via InterQual.
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 UnitedHealthcare policy.
Source
Summarized from UnitedHealthcare Commercial Medical Policy Surgery of the Shoulder (2026T0556FF, eff 2026-01-01). Source: View the source policy. Last verified 2026-06-13.
Frequently asked questions
Does UnitedHealthcare require prior authorization for Total Shoulder Arthroplasty?
Yes. UnitedHealthcare generally requires prior authorization for Total Shoulder Arthroplasty (CPT 23472).
What does UnitedHealthcare require to approve Total Shoulder Arthroplasty?
UnitedHealthcare reviews total shoulder replacement against InterQual CP: Procedures (Joint Replacement, Shoulder), policy 2026T0556FF (Surgery of the Shoulder). Proven and medically necessary in certain circumstances; specific thresholds (documented glenohumeral osteoarthritis or cuff-tear arthropathy, failed non-operative care) are adjudicated via InterQual. Always confirm against the current UnitedHealthcare policy.
How long does a UnitedHealthcare prior authorization take?
Turnaround varies by plan and submission method. Check the UnitedHealthcare portal for current timeframes.
Submitting Total Shoulder Arthroplasty to UnitedHealthcare?
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.