10136
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Documentation supporting medical necessity and a clearly stated plan of care must be submitted at the time of the request and must include the components described, including clinical notes detailing symptom duration/severity, functional limitations, and the type/duration of all therapeutic measures provided; if conservative management is not appropriate, the reason must be documented.
- Documentation: Documentation supporting medical necessity and a clearly stated plan of care must be provided at the time of the request.
- Documentation: Conservative management must include a combination of strategies (including physical therapy) and at least one complementary conservative treatment.
- Documentation: Imaging reports within the past 12 months describing degree of cartilage damage.
Key Coverage Criteria
- Indication: Proximal humerus fracture not amenable to internal fixation.
- Indication: Advanced shoulder joint disease due to OA/RA/AVN/post-traumatic arthritis when ALL the following requirements are met.
2 Active Policies
CARELON-joint-surgery-2024-11-17-updated-2025-01-01, Joint Surgery
CARELON-joint-surgery-2025-11-15, Joint Surgery
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