Shoulder Surgery Insurance Denial Appeal Guide

Why Shoulder Surgery Gets Denied

Rotator cuff repairs and shoulder arthroscopy are common targets for utilization review denials. Insurers want extensive conservative treatment documentation before approving surgery.

Common Denial Reasons

• Insufficient conservative treatment trial (need 6+ weeks of PT)
• Partial tear vs full-thickness tear documentation
• Imaging doesn't show surgical pathology
• Prior authorization not obtained
• Questionable medical necessity for arthroscopic debridement

How to Appeal

1. Document PT failure — at least 6 weeks, ideally 12 weeks of supervised physical therapy
2. MRI showing tear size and location — full-thickness tears have higher approval rates
3. Functional limitations — inability to perform work duties, ADL restrictions
4. Conservative treatment history — steroid injections, NSAIDs, activity modification
5. Surgeon letter explaining why continued conservative treatment is futile

Timing Matters

For rotator cuff tears, delays in surgical repair can lead to muscle atrophy, tendon retraction, and worse surgical outcomes. Include this in your appeal to counter "try more PT" denials.