CommercialCoverageHigh impact
Shoulder Arthroplasty (Total, Partial, Reverse, Revision and Resurfacing) 7.01.95
Excellus BlueCross BlueShield·Orthopedics·Bone & Joints (Orthopedic)
Effective date
Oct 15, 2025
We identified it
Jun 20, 2026
Summary
Excellus BlueCross BlueShield has updated their shoulder arthroplasty policy effective October 15, 2025, establishing detailed medical necessity criteria for total, partial, reverse, and revision shoulder replacements. The policy requires specific imaging findings, 3-month duration of function-limiting pain, and failed conservative management for most procedures, with shoulder resurfacing considered investigational.
Action Required
By October 15, 2025: Billing team must update prior authorization processes to ensure all shoulder arthroplasty cases meet the new medical necessity criteria including: radiographic evidence of joint disease, documented 3+ months of function-limiting pain, and failed conservative treatment for 3+ months. Update encounter forms to prompt providers for required documentation. Claims not meeting these criteria will be denied.