Why Aetna Denies Shoulder Arthroscopy / Rotator Cuff Repair
Conservative therapy not exhausted (PT, injections)
Partial tear does not meet surgical threshold
Imaging does not correlate with symptoms
Know Aetna's Criteria
Aetna uses their own Clinical Policy Bulletins (CPBs) and InterQual criteria. CPBs are publicly available and numbered.
Key policies to know:
- Clinical Policy Bulletins (CPBs) are publicly available and numbered
- Uses eviCore for radiology and cardiology prior auth
- Known for detailed, evidence-based CPBs with specific criteria
- Precertification list updated annually
Building Your Medical Necessity Argument
Document tear size and location on MRI
Show failure of 3-6 months PT and at least one subacromial injection
Note functional limitations and pain severity
Reference full-thickness tear or significant partial tear (>50%)
P2P Call Tips for Aetna
Reference the specific CPB number and criteria being met
Aetna CPBs are very detailed -- read them before the call
Address each specific criterion in the CPB during the P2P
Aetna medical directors are typically receptive to guideline-based arguments
Guidelines to Reference
- AAOS Clinical Practice Guidelines for Rotator Cuff
- AIM Specialty Health Shoulder Surgery Guidelines
Relevant CPT Codes
Specialty: Orthopedics
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