What documentation does Anthem require for CPT 29827?

Shoulder MRI; PT records; Conservative treatment documentation; Surgical evaluation

How much does Medicare pay for CPT 29827 in 2026?

In 2026, the national Medicare allowable for CPT 29827 is $976.31 in an office setting and $976.31 in a facility. Commercial allowables for Anthem are typically negotiated against this benchmark.

What if Anthem denies the PA for CPT 29827?

Appeal in writing within 60 days, citing the specific clinical policy criteria the case meets and attaching supporting documentation. Many denials are reversed on first-level appeal when the criteria language is mirrored.

Prior Authorization

Anthem Prior Authorization for CPT 29827

Arthroscopy procedures with site of service review (except in certain states) · Standard commercial plans

Prior authorization REQUIREDApplies to all statesLast verified January 1, 2026 · Reviewed by the D3rx Clinical Billing Team

Source

Anthem clinical policy

Not medical advice. PA policies change frequently. Always confirm against the payer's current policy before submitting. d3rx pulls directly from publicly published policy PDFs and refreshes daily.

Clinical criteria

Anthem requires prior authorization for arthroscopic rotator cuff repair. Must document MRI-confirmed rotator cuff tear, 6+ weeks of failed non-operative treatment, and functional impairment. Acute traumatic tears with documented mechanism of injury may qualify without conservative therapy trial.

Documentation checklist

✓Shoulder MRI
✓PT records
✓Conservative treatment documentation
✓Surgical evaluation

Submission channels

Phone

1-800-274-7767

2026 Medicare rate for CPT 29827

Office (non-facility)

$976.31

Facility

$976.31

Total RVUs (office)

29.23

Conversion factor

$33.4009

National Medicare Physician Fee Schedule amounts (GPCI 1.0). Anthem's commercial allowable is negotiated against this benchmark — see the full RVU and locality breakdown on the CPT 29827 code page.

How to submit the PA

1Verify the requirement against the current clinical policy linked above.
2Gather documentation: Shoulder MRI, PT records, Conservative treatment documentation….
3Submit via phone, or the payer portal.
4Document the reference number and follow up within 5 business days if no determination is received.

FAQ

Does Anthem require prior authorization for CPT 29827?: Yes. Anthem requires prior authorization for CPT 29827 (Arthroscopy procedures with site of service review (except in certain states)) under Standard commercial plans per its published clinical policy.
What documentation does Anthem require for CPT 29827?: Shoulder MRI; PT records; Conservative treatment documentation; Surgical evaluation
How much does Medicare pay for CPT 29827 in 2026?: In 2026, the national Medicare allowable for CPT 29827 is $976.31 in an office setting and $976.31 in a facility. Commercial allowables for Anthem are typically negotiated against this benchmark.
What if Anthem denies the PA for CPT 29827?: Appeal in writing within 60 days, citing the specific clinical policy criteria the case meets and attaching supporting documentation. Many denials are reversed on first-level appeal when the criteria language is mirrored.

Other Anthem PA lookups

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All Anthem prior-authorization requirements →

CPT 29827 prior authorization by payer

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