Billing and Coding: Total Shoulder Arthroplasty

Total shoulder arthroplasty is covered only when the procedure meets the medical necessity criteria of Local Coverage Determination L39956. Coverage requires complete medical record documentation—including history, physical exam, and relevant diagnostic test results—that supports medical necessity and must be made available to the contractor upon request; absence of such documentation may result in denial. Detailed eligibility, exclusions, and other criteria are specified in LCD L39956 and should be consulted for case-specific determination.

"Total shoulder arthroplasty is covered when the medical necessity criteria of the Local Coverage Determination L39956 are met."

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