23474
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
26.53
Facility
$1552.14
Non-Facility
$1552.14
Documentation Required
- Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage but does not guarantee coverage of the service requested; refer to the protocol titled Medical Records Documentation Used for Reviews.
- When deciding coverage, the member specific benefit plan document must be referenced as the terms of the member specific benefit plan may differ from the standard plan. In the event of a conflict, the member specific benefit plan document governs.
- UnitedHealthcare may use InterQual® CP clinical criteria as the medical necessity standard; documentation should support meeting the applicable InterQual® criteria for the requested procedure(s).
- Documentation that may be relevant (implicit/typical) includes clinical notes, imaging (e.g., MRI), physical examination findings, documentation of prior conservative therapy and its duration, operative notes, and any other records required to demonstrate that member-specific and InterQual® criteria are met (policy references the general protocol 'Medical Records Documentation Used for Reviews').
Key Coverage Criteria
- InterQual® CP: Procedures - Arthroscopy or Arthroscopically Assisted Surgery, Shoulder (Adolescent) (used as the medical necessity clinical coverage criteria).
- Surgery of the shoulder is proven and medically necessary in certain circumstances.
- InterQual® CP: Procedures - Arthroscopy or Arthroscopically Assisted Surgery, Shoulder (used as the medical necessity clinical coverage criteria).
- InterQual® CP: Procedures - Arthroscopy, Diagnostic, +/- Synovial Biopsy, Shoulder (used as the medical necessity clinical coverage criteria).
- InterQual® CP: Procedures - Joint Replacement, Shoulder (used as the medical necessity clinical coverage criteria).
- InterQual® CP: Procedures - Removal and Replacement or Revision, Joint Replacement, Shoulder (used as the medical necessity clinical coverage criteria).
3 Active Policies
UHC-POL-surgery-shoulder — Surgery of the Shoulder
UMR-POL-UMR-surgery-shoulder — Surgery of the Shoulder
SUREST-POL-SUREST-surgery-shoulder — Surgery of the Shoulder
Related Codes
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