The following policy is effective 06/01/2021 and applies to Cigna Fully Insured and Self-Funded Plans.
Background: CMS and an evidence-based guidelines from MCG Health designate shoulder arthroplasty procedures (CPT codes 23470 & 23472) as outpatient, when medically appropriate.
Starting 06/01/2021- Cigna may deny CPT 23470 & 23472, when requested for inpatient level of care. (inpatient setting).
eviCore will review the inpatient level of care requests for medical necessity and level of care. eviCore will base its review of medical necessity based on MCG Health criteria.
Denials will include the medical necessity appeal rights.
The above policy is basically the site-of-care policy for Cigna Fully Insured and Self-Funded Plans.
Possible Solution to avoid unnecessary Denials: Make sure you review the Cigna Shoulder Arthroplasty Policy and CIGNA Site-of-Care Policy. Site-of-Care policy will give you the criteria for the patient to qualify for the inpatient setting and receive inpatient level of care as oppose to outpatient setting (ASC).
(Shoulder Arthroplasty Policy is updated for 07/01/2021) Please visit the links above for the FULL CIGNA POLICIES.