S42.201A — Unspecified fracture of upper end of right humerus, initial encounter for closed fracture
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Documentation must be made available to the contractor upon request.
- All documentation must be maintained in the patient's medical record and must support the medical necessity of the service as directed in this article and LCD L39956.
- Medical record documentation must include relevant medical history, physical examination findings, and results of pertinent diagnostic tests or procedures.
- Radiographic evidence documenting the diagnosis (examples: irregular joint surfaces, subchondral cysts, glenoid flattening or sclerosis, periarticular osteophytes, joint subluxation, joint space narrowing, or avascular necrosis) must be in the medical record.
Key Coverage Criteria
- Total shoulder arthroplasty is covered when the medical necessity criteria of the Local Coverage Determination L39956 are met.
- Total shoulder arthroplasty (TSA) is indicated for degenerative glenohumeral joint disease (including osteoarthritis, post-traumatic arthritis, rheumatoid arthritis, osteonecrosis, or arthropathy with rotator cuff deficit) when there is documented radiographic evidence of the diagnosis, documented moderate-to-severe chronic pain or chronic functional disability for at least 12 weeks, and at least 12 weeks of unsuccessful conservative therapy (or a documented reason why conservative therapy is no [...]
- TSA is indicated for treatment of acute proximal humerus fractures (PHFs) that are not amenable to conservative therapy or internal fixation.
- TSA is indicated for treatment of nonunion or malunion of proximal humerus fractures with radiographic evidence of nonunion or malunion.
- TSA is indicated for reconstruction following tumor resection of the glenohumeral joint, proximal humerus, or adjacent tissue.
- Reverse TSA or TSA is indicated for massive irreparable rotator cuff tears (MIRCTs) when MRI or arthroscopy documents a massive rotator cuff tear (examples: tear size >5 cm in AP or ML orientation, tear of two or more tendons, or tendon retraction to the glenoid rim with >2/3 greater tuberosity exposed), pseudo-paralysis (active elevation <90° against gravity), and at least 12 weeks of unsuccessful conservative therapy including 12 weeks of supervised physical therapy (or documented reason why s [...]
4 Active Policies
A59877 — Billing and Coding: Total Shoulder Arthroplasty
AETNA-CPB-0778 — Robotic-assisted Rehabilitation of the Extremities
A59878 — Billing and Coding: Total Shoulder Arthroplasty
L39956 — Total Shoulder Arthroplasty
Related Codes
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