Effective August 1, 2014, Harvard Pilgrim will require prior authorization for the following shoulder arthroscopy procedures provided to members of our HMO, POS, or PPO products:
- 23412 — Repair of ruptured musculotendinous cuff (e.g. rotator cuff) open; chronic
- 23415 — Coracoacromial ligament release, with or without acromioplasty
- 29807 — Arthroscopy, shoulder, surgical; repair of SLAP lesion
- 29822 — Arthroscopy, shoulder, surgical; debridement, limited
- 29823 — Arthroscopy, shoulder, surgical; debridement, extensive
- 29824 — Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford procedure)
- 29826 — Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with or without coracoacromial release
This policy is aimed at providing the best clinical outcome for our members and is consistent with current clinical literature that recommends pursuing conservative therapies prior to performing one of these surgeries. To receive authorization for one of the shoulder arthroscopy procedures listed above, please provide medical record documentation confirming all of the following:
- The member has received at least 3 weeks of NSAID therapy and/or cortisone injection. If NSAID therapy or cortisone injection is contraindicated, please provide documentation explaining the contraindication.
- The member has completed at least 12 weeks of physical or occupational therapy related to the shoulder condition, and/or a 12-week clinician directed home exercise/activity modification program for the shoulder condition in the last 6 months. (PT and OT benefit limits still apply. Because PT/OT benefit limits vary, please be mindful of the members’ PT/OT benefit when planning treatment.)
- Appropriate imaging studies of the shoulder (e.g. plain films, MRI) have been completed.
When requesting prior authorization for these procedures, please fax a completed Prior Authorization Request — Shoulder Arthroscopy form to Harvard Pilgrim at 800-232-0816. If you have any questions about this process, please refer to the Shoulder Arthroscopy Medical Review Criteria on our provider website or contact the Provider Service Center at 800-708-4414, and select the option for the Referral/Authorization Unit.