23107
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
8.65
Facility
$626.27
Non-Facility
$626.27
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.
- Inpatient admission is medically necessary when current postoperative care requirements are of such intensity or duration that they cannot be met in an observation or outpatient setting.
- Inpatient admission is medically necessary when anticipated postoperative care requirements cannot be met in an observational surgical setting due to complexity, duration, or extent of the planned procedure or substantial preoperative patient risk.
- Inpatient admission is medically necessary when preoperative ASA status is ≥ IV (see Appendix).
- Inpatient admission is medically necessary when distance from the nearest hospital emergency room poses a clinically significant risk for emergent post-operative complications.
3 Active Policies
CARELON-joint-surgery-2024-11-17-updated-2025-01-01, Joint Surgery
CARELON-joint-surgery-2025-11-15, Joint Surgery
CARELON-level-of-care-for-surgical-procedures-2025-11-15, Level of Care for Surgical Procedures
Related Codes
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