Aetna Shoulder Arthroplasty and Arthrodesis coverage criteria

What this means for the claim

The covered path, the next step to get it approved, and the specific way it denies — built only from this policy.

Coverage criteria

• Total (anatomic) shoulder arthroplasty with an FDA-approved prosthesis is medically necessary for adults when ALL of the following are met: (1) advanced joint disease demonstrated by ALL of [pain/functional disability from osteoarthritis, rheumatoid arthritis, avascular necrosis, or post-traumatic arthritis; limited range of motion or crepitus on exam; severe pain >=6 months interfering with ADLs; radiographic evidence (TWO or more of: irregular joint surfaces, glenoid sclerosis, osteophytes, flattened glenoid, cystic changes, joint-space narrowing); documented history of unsuccessful conservative therapy] OR proximal humeral fracture/nonunion/malunion with pain interfering with ADLs OR glenohumeral malignancy.
• Anatomic total shoulder arthroplasty conservative-therapy requirement: at least 12 weeks of non-surgical treatment documented, with at least half consisting of in-person formal physical therapy with a licensed physical therapist in the past year, including anti-inflammatories/analgesics, flexibility/strengthening exercises, activity modification, supervised PT, and (optional) intra-articular steroid injections. WAIVED for: glenoid bone loss with anterior/posterior subluxation, OR avascular necrosis with collapse plus severe osteoarthritis.
• Reverse total shoulder arthroplasty is medically necessary for adults with ONE of the following indications: deficient rotator cuff with glenohumeral arthropathy; OR failed hemiarthroplasty; OR failed total shoulder arthroplasty with non-repairable rotator cuff; OR massive rotator cuff tears with pseudo-paralysis without osteoarthritis; OR tumor-resection reconstruction; OR proximal humeral fractures not repairable by other techniques.
• Reverse total shoulder arthroplasty additionally requires ALL of: pain/functional disability >=6 months interfering with ADLs (6-month duration WAIVED for fractures/tumor reconstruction); clearly documented history of unsuccessful conservative therapy (same 12-week / >=50% in-person formal PT standard as TSA); intact deltoid; adequate bone stock for firm implant fixation; >=90 degrees passive shoulder elevation/flexion; and no conditions causing excessive implant stress (e.g., Charcot joint).
• Reverse total shoulder arthroplasty conservative-therapy requirement is WAIVED (not required) for: fractures, tumor reconstruction, glenoid bone loss with anterior/posterior subluxation, or avascular necrosis with collapse.
• Shoulder hemiarthroplasty is medically necessary for adults with ONE of the following indications: rotator cuff tear arthropathy (severe tearing plus end-stage disease); OR radiographic destructive degenerative joint disease (osteoarthritis or rheumatoid arthritis); OR osteonecrosis without glenoid involvement; OR inadequate glenoid bone stock; OR proximal humerus fracture not amenable to internal fixation.
• Shoulder hemiarthroplasty additionally requires ALL of: pain/functional disability >=6 months interfering with ADLs (6-month duration WAIVED for humeral fracture); documented history of unsuccessful conservative therapy (12-week / >=50% in-person formal PT standard); and no paralytic shoulder disorder.
• Shoulder hemiarthroplasty conservative-therapy requirement is WAIVED (not required) for: humeral fracture or avascular necrosis with collapse.
• Shoulder arthrodesis is medically necessary for ONE of the following indications: active tuberculosis or bacterial joint infection; OR brachial plexus palsy with flail shoulder; OR recurrent shoulder dislocation; OR tumor resection; OR irreparable rotator cuff tears; OR failed total shoulder arthroplasty; OR paralytic disorders of infancy.
• Shoulder arthrodesis additionally requires ALL of: chronic, severe pain/functional disability interfering with ADLs; imaging evidence confirming the diagnosis; and documented history of unsuccessful conservative therapy (12-week treatment, with >=50% as in-person formal physical therapy), with components including anti-inflammatories/analgesics, activity modification, supervised PT, and assistive-device use as appropriate. For conditions where a non-surgical approach is not reasonable, the medical record must document why conservative therapy was not pursued (WAIVER must be documented).
• Revision/replacement of a shoulder arthroplasty prosthesis is medically necessary for ONE of the following indications, each with pain/functional disability interfering with ADLs: aseptic loosening of >=1 component confirmed by imaging; OR prosthetic component fracture confirmed by imaging; OR displaced peri-prosthetic fracture; OR progressive/substantial peri-prosthetic bone loss; OR bearing-surface wear causing symptomatic synovitis; OR confirmed peri-prosthetic infection (gram stain/culture) [single-stage revision is standard; multi-stage considered for prior same-joint infection]; OR glenoid/humeral component instability or dislocation; OR humeral head migration.
• Conservative-therapy verbatim standard (applies across TSA, reverse TSA, hemiarthroplasty, and arthrodesis): members should have at least 12 weeks of non-surgical treatment documented in the medical record, with at least half of the necessary conservative therapy consisting of in-person formal physical therapy with a licensed physical therapist in the past year.

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

• 23472·PA verdict·Rate
• 23474·PA verdict·Rate

Documentation required

• Physical therapy documentation must include actual PT notes OR member claims history.
• A minimum of 12 weeks of non-surgical treatment must be documented in the medical record.
• At least 50% of the conservative therapy must be in-person formal physical therapy with a licensed physical therapist in the past year.
• For conditions where the conservative-therapy requirement is waived, the medical record must clearly document why a non-surgical approach is not reasonable.
• For revisions/replacement: imaging confirmation of the indication (e.g., loosening, component fracture, peri-prosthetic fracture, bone loss).
• For peri-prosthetic infection: gram stain and culture confirmation.

Frequently asked questions

When does Aetna cover Shoulder Arthroplasty and Arthrodesis (CPT 23472), and what gets it denied?

Aetna CPB 0837 covers shoulder arthroplasty procedures (anatomic total, reverse total, and hemiarthroplasty), shoulder arthrodesis, and prosthesis revision/replacement as medically necessary when documented advanced joint disease, fracture, tumor, or rotator-cuff/implant-failure indications are met. The core gate for elective degenerative cases is failure of at least 12 weeks of conservative therapy (with at least half as in-person formal physical therapy in the past year), waived for fractures, tumors, and certain bone-loss/avascular-necrosis presentations. Numerous adjuncts (AR/VR and computer-assisted navigation, custom instrumentation/implants, cage glenoid, superior capsular reconstruction, sub-acromial balloon spacer, micro-fracturing, 3D imaging) and TSA for ochronotic arthritis or irreparable rotator cuff tear are considered experimental/investigational. Coverage criteria include: Total (anatomic) shoulder arthroplasty with an FDA-approved prosthesis is medically necessary for adults when ALL of the following are met: (1) advanced joint disease demonstrated by ALL of [pain/functional disability from osteoarthritis, rheumatoid arthritis, avascular necrosis, or post-traumatic arthritis; limited range of motion or crepitus on exam; severe pain >=6 months interfering with ADLs; radiographic evidence (TWO or more of: irregular joint surfaces, glenoid sclerosis, osteophytes, flattened glenoid, cystic changes, joint-space narrowing); documented history of unsuccessful conservative therapy] OR proximal humeral fracture/nonunion/malunion with pain interfering with ADLs OR glenohumeral malignancy.; Anatomic total shoulder arthroplasty conservative-therapy requirement: at least 12 weeks of non-surgical treatment documented, with at least half consisting of in-person formal physical therapy with a licensed physical therapist in the past year, including anti-inflammatories/analgesics, flexibility/strengthening exercises, activity modification, supervised PT, and (optional) intra-articular steroid injections. WAIVED for: glenoid bone loss with anterior/posterior subluxation, OR avascular necrosis with collapse plus severe osteoarthritis.; Reverse total shoulder arthroplasty is medically necessary for adults with ONE of the following indications: deficient rotator cuff with glenohumeral arthropathy; OR failed hemiarthroplasty; OR failed total shoulder arthroplasty with non-repairable rotator cuff; OR massive rotator cuff tears with pseudo-paralysis without osteoarthritis; OR tumor-resection reconstruction; OR proximal humeral fractures not repairable by other techniques.; Reverse total shoulder arthroplasty additionally requires ALL of: pain/functional disability >=6 months interfering with ADLs (6-month duration WAIVED for fractures/tumor reconstruction); clearly documented history of unsuccessful conservative therapy (same 12-week / >=50% in-person formal PT standard as TSA); intact deltoid; adequate bone stock for firm implant fixation; >=90 degrees passive shoulder elevation/flexion; and no conditions causing excessive implant stress (e.g., Charcot joint).; Reverse total shoulder arthroplasty conservative-therapy requirement is WAIVED (not required) for: fractures, tumor reconstruction, glenoid bone loss with anterior/posterior subluxation, or avascular necrosis with collapse.; Shoulder hemiarthroplasty is medically necessary for adults with ONE of the following indications: rotator cuff tear arthropathy (severe tearing plus end-stage disease); OR radiographic destructive degenerative joint disease (osteoarthritis or rheumatoid arthritis); OR osteonecrosis without glenoid involvement; OR inadequate glenoid bone stock; OR proximal humerus fracture not amenable to internal fixation.; Shoulder hemiarthroplasty additionally requires ALL of: pain/functional disability >=6 months interfering with ADLs (6-month duration WAIVED for humeral fracture); documented history of unsuccessful conservative therapy (12-week / >=50% in-person formal PT standard); and no paralytic shoulder disorder.; Shoulder hemiarthroplasty conservative-therapy requirement is WAIVED (not required) for: humeral fracture or avascular necrosis with collapse.; Shoulder arthrodesis is medically necessary for ONE of the following indications: active tuberculosis or bacterial joint infection; OR brachial plexus palsy with flail shoulder; OR recurrent shoulder dislocation; OR tumor resection; OR irreparable rotator cuff tears; OR failed total shoulder arthroplasty; OR paralytic disorders of infancy.; Shoulder arthrodesis additionally requires ALL of: chronic, severe pain/functional disability interfering with ADLs; imaging evidence confirming the diagnosis; and documented history of unsuccessful conservative therapy (12-week treatment, with >=50% as in-person formal physical therapy), with components including anti-inflammatories/analgesics, activity modification, supervised PT, and assistive-device use as appropriate. For conditions where a non-surgical approach is not reasonable, the medical record must document why conservative therapy was not pursued (WAIVER must be documented).; Revision/replacement of a shoulder arthroplasty prosthesis is medically necessary for ONE of the following indications, each with pain/functional disability interfering with ADLs: aseptic loosening of >=1 component confirmed by imaging; OR prosthetic component fracture confirmed by imaging; OR displaced peri-prosthetic fracture; OR progressive/substantial peri-prosthetic bone loss; OR bearing-surface wear causing symptomatic synovitis; OR confirmed peri-prosthetic infection (gram stain/culture) [single-stage revision is standard; multi-stage considered for prior same-joint infection]; OR glenoid/humeral component instability or dislocation; OR humeral head migration.; Conservative-therapy verbatim standard (applies across TSA, reverse TSA, hemiarthroplasty, and arthrodesis): members should have at least 12 weeks of non-surgical treatment documented in the medical record, with at least half of the necessary conservative therapy consisting of in-person formal physical therapy with a licensed physical therapist in the past year.. Applies to 2 codes: 23472, 23474. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Precertification may be required for select procedures and interventions. Use the CPT code search tool to see if precertification is required. Documentation: Physical therapy documentation must include actual PT notes OR member claims history.; A minimum of 12 weeks of non-surgical treatment must be documented in the medical record.; At least 50% of the conservative therapy must be in-person formal physical therapy with a licensed physical therapist in the past year.; For conditions where the conservative-therapy requirement is waived, the medical record must clearly document why a non-surgical approach is not reasonable.; For revisions/replacement: imaging confirmation of the indication (e.g., loosening, component fracture, peri-prosthetic fracture, bone loss).; For peri-prosthetic infection: gram stain and culture confirmation. Policy exclusions and limitations: Experimental/investigational/unproven: Total shoulder arthroplasty for ochronotic arthritis.; Experimental/investigational/unproven: Total shoulder arthroplasty in persons with glenohumeral osteoarthritis who have an irreparable rotator cuff tear.; Experimental/investigational/unproven: Total shoulder arthroplasty with a cage glenoid prosthesis (long-term effectiveness not established).; Experimental/investigational/unproven: Augmented or virtual reality (AR/VR) assistance for shoulder arthroplasty.; Experimental/investigational/unproven: Computer-assisted musculoskeletal surgical navigation for shoulder arthroplasty.; Experimental/investigational/unproven: Custom instrumentation for the procedure, including cutting blocks.; Experimental/investigational/unproven: Custom joint implants.; Experimental/investigational/unproven: Micro-fracturing of the shoulder.; Experimental/investigational/unproven: Pre-operative advanced imaging required for experimental procedures.; Experimental/investigational/unproven: Sub-acromial balloon spacer for rotator cuff tears.; Experimental/investigational/unproven: Superior capsular reconstruction for rotator cuff tears.; Experimental/investigational/unproven: Three-dimensional (3D) pre-operative imaging for total shoulder arthroplasty.; Experimental/investigational/unproven: Univers Revers System for metaphyseal fixation in reverse shoulder arthroplasty.; Experimental/investigational/unproven: Use of acellular dermal extracellular matrix for shoulder capsular reconstruction.; Contraindication (non-coverage) to arthroplasty/hemiarthroplasty/reverse arthroplasty: active infection of the joint or active systemic bacteremia not totally eradicated (this contraindication does not apply to revision/replacement).; Contraindication (non-coverage): active skin infection (except recurrent cutaneous staphylococcal infection) or open wound within the planned surgical site.; Contraindication (non-coverage): corticosteroid injection into the joint within 12 weeks of planned arthroplasty.; Contraindication (non-coverage): rapidly progressive neurological disease.; Contraindication (non-coverage): allergy to implant components (cobalt, chromium, alumina).; Not medically necessary / not covered: total shoulder arthroplasty for glenohumeral osteoarthritis with an irreparable rotator cuff tear.; Not medically necessary / not covered: total shoulder arthroplasty for ochronotic arthritis. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Does Aetna require prior authorization for Shoulder Arthroplasty and Arthrodesis?

Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Precertification may be required for select procedures and interventions. Use the CPT code search tool to see if precertification is required. Documentation: Physical therapy documentation must include actual PT notes OR member claims history.; A minimum of 12 weeks of non-surgical treatment must be documented in the medical record.; At least 50% of the conservative therapy must be in-person formal physical therapy with a licensed physical therapist in the past year.; For conditions where the conservative-therapy requirement is waived, the medical record must clearly document why a non-surgical approach is not reasonable.; For revisions/replacement: imaging confirmation of the indication (e.g., loosening, component fracture, peri-prosthetic fracture, bone loss).; For peri-prosthetic infection: gram stain and culture confirmation.

What does Aetna exclude for Shoulder Arthroplasty and Arthrodesis?

Policy exclusions and limitations: Experimental/investigational/unproven: Total shoulder arthroplasty for ochronotic arthritis.; Experimental/investigational/unproven: Total shoulder arthroplasty in persons with glenohumeral osteoarthritis who have an irreparable rotator cuff tear.; Experimental/investigational/unproven: Total shoulder arthroplasty with a cage glenoid prosthesis (long-term effectiveness not established).; Experimental/investigational/unproven: Augmented or virtual reality (AR/VR) assistance for shoulder arthroplasty.; Experimental/investigational/unproven: Computer-assisted musculoskeletal surgical navigation for shoulder arthroplasty.; Experimental/investigational/unproven: Custom instrumentation for the procedure, including cutting blocks.; Experimental/investigational/unproven: Custom joint implants.; Experimental/investigational/unproven: Micro-fracturing of the shoulder.; Experimental/investigational/unproven: Pre-operative advanced imaging required for experimental procedures.; Experimental/investigational/unproven: Sub-acromial balloon spacer for rotator cuff tears.; Experimental/investigational/unproven: Superior capsular reconstruction for rotator cuff tears.; Experimental/investigational/unproven: Three-dimensional (3D) pre-operative imaging for total shoulder arthroplasty.; Experimental/investigational/unproven: Univers Revers System for metaphyseal fixation in reverse shoulder arthroplasty.; Experimental/investigational/unproven: Use of acellular dermal extracellular matrix for shoulder capsular reconstruction.; Contraindication (non-coverage) to arthroplasty/hemiarthroplasty/reverse arthroplasty: active infection of the joint or active systemic bacteremia not totally eradicated (this contraindication does not apply to revision/replacement).; Contraindication (non-coverage): active skin infection (except recurrent cutaneous staphylococcal infection) or open wound within the planned surgical site.; Contraindication (non-coverage): corticosteroid injection into the joint within 12 weeks of planned arthroplasty.; Contraindication (non-coverage): rapidly progressive neurological disease.; Contraindication (non-coverage): allergy to implant components (cobalt, chromium, alumina).; Not medically necessary / not covered: total shoulder arthroplasty for glenohumeral osteoarthritis with an irreparable rotator cuff tear.; Not medically necessary / not covered: total shoulder arthroplasty for ochronotic arthritis. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Source

Related

• All Aetna coverage policies
• Aetna prior-authorization requirements — which codes need PA, by CPT