What this page covers
Musculoskeletal is the most-delegated PA category in commercial insurance. eviCore MSK, Carelon Musculoskeletal, and Optum MSK together handle well over half of US commercial orthopedic and spine PAs. The denial pattern is consistent across all three: missing conservative therapy, missing functional-status measurement, or missing imaging that matches the planned procedure level. This page walks the workflow by sub-specialty and shows where AI agents close the gaps before first submission.
Orthopedic surgery: joint replacement, arthroscopy, fracture care
Total joint arthroplasty is the highest-volume PA procedure in orthopedics. Total knee arthroplasty (CPT 27447), total hip (27130), total shoulder (23472), and revision codes all require a standardized documentation set: imaging-confirmed osteoarthritis or AVN, symptom duration, conservative therapy (PT, NSAIDs, injections, weight loss counseling) over 6-12 weeks, functional-status measures (KOOS, HOOS, or WOMAC), and BMI. Plans that include BMI thresholds (commonly 40-45) will deny until documented weight loss attempts are attached.
Arthroscopy codes (29881 knee meniscectomy, 29827 rotator cuff repair, 29826 subacromial decompression) are lighter-lift PAs but volume-heavy. Payers want the MRI, failed conservative therapy, and an injection history for symptomatic shoulder work. Fracture care is rarely PA'd acutely but elective fixation cases and hardware removal (20680) do trigger PA with many MA plans.
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Spine surgery
Spine is the most scrutinized PA category in commercial insurance. Lumbar fusion (22612, 22630, 22633), anterior cervical discectomy and fusion (ACDF, 22551, 22554), posterior cervical fusion (22600), and lumbar decompression (63047, 63030) each carry separate medical-necessity criteria. Payers want imaging with spondylolisthesis grading or instability on flexion-extension, documented radiculopathy matching the surgical level, 6-12 weeks of failed conservative therapy including PT and often injections, and a surgeon operative plan. Multi-level fusion triggers additional review, and cervical fusion above two levels typically requires peer-to-peer.
eviCore spine policy and Carelon musculoskeletal policy both published stricter criteria in 2025-2026, narrowing acceptable indications for lumbar fusion in particular. Denials for "insufficient evidence of instability" are common when the imaging report uses ambiguous language. Flexbone flags these before submission by matching the radiology impression against the payer's accepted language list.
Sports medicine
ACL reconstruction (29888), meniscal repair (29882), rotator cuff repair (29827), SLAP repair (29807), and cartilage procedures (27412 MACI, 29867 OCD grafts) dominate sports medicine PA volume. Cartilage work and biologic procedures (PRP, BMAC, stem cell) are the hardest to authorize because payer policies are split. MACI (autologous chondrocyte implantation) has a specific PA packet requirement across most commercial plans. PRP and stem cell injections are often denied as experimental and require specific CPT/HCPCS code matching.
Interventional pain management
Pain management is volume-dense PA work. A busy interventional pain practice runs 40-80 PAs per provider per week across injections, nerve blocks, RFA, and device implants.
Epidural steroid injections (62321, 62323) require PA with most commercial and MA plans. Payers cap the number per year (often 3-4 per region), require documented radiculopathy at the injection level, failed conservative therapy, and imaging support. eviCore interventional pain criteria tightened ESI approval in 2025-2026.
Medial branch blocks (64493-64495) and RFA (64633-64636) have a sequenced PA requirement: two positive MBBs with documented pain relief before RFA is approved. Missing the second block documentation is the most common RFA denial reason.
Spinal cord stimulator PA is two stages: the trial (63650) requires chronic pain over 6 months, failed back surgery syndrome or CRPS diagnosis, conservative-therapy failure, and psychological evaluation clearance. The permanent implant (63685) requires successful trial documentation showing over 50 percent pain reduction. Trial-to-implant conversion denials most often come from missing psych clearance or incomplete trial pain diaries.
Kyphoplasty (22513-22515) requires failed conservative therapy, painful vertebral compression fracture documented on MRI or bone scan, and often a specific time window from fracture.
Podiatric surgery
Podiatric surgery PA covers bunionectomy (28296, 28297, 28299), hammertoe correction (28285), neuroma excision (28080), and ankle arthroscopy (29895, 29897). Medicare and many MA plans cover routine podiatric care only when a systemic condition (diabetes with complications, PAD) is documented. Bunion surgery PA almost always requires failed conservative therapy, imaging with hallux valgus angle measurement, and functional limitation documentation.
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Payer-specific MSK PA rules
| Payer | MSK PA delegated to | Notes |
|---|---|---|
| UnitedHealthcare | Optum MSK (in-house) | Advance notification for some joint and spine procedures |
| Aetna (commercial + MA) | eviCore MSK | Spine fusion and joint TJA require full conservative therapy documentation |
| Cigna (commercial) | eviCore MSK | Strict rotator cuff and shoulder PA criteria |
| Humana (MA) | eviCore MSK | Extensive documentation for pain management injections |
| Anthem / Elevance BCBS | Carelon MSK | Aligned MSK policy across states |
| BCBS plans (non-Anthem) | Varies by state, eviCore or Carelon | Check state plan policy |
| Workers comp | Sedgwick, Gallagher Bassett, CorVel, Concentra | TPA-specific portals and UR criteria |
Full payer detail at commercial payers and BCBS plans. For MA-specific rules see Medicare, Medicaid, and government payer PA.
Orthopedic EHRs, PACS, and outcomes platforms
- Ambulatory EHRs: athenahealth, NextGen Orthopedic, eClinicalWorks, Allscripts/Veradigm, Greenway Intergy.
- Specialty-specific: ModMed Ortho, Nextech Ortho, OrthoLogic (MedAxiom), PracticeMaster. Details at outpatient EHRs for PA.
- PACS and imaging: Merge, Synapse, Sectra, Intelerad. Flexbone reads imaging reports, not the pixel data.
- Outcomes: OBERD, CODE, PatientIQ. PA packets often pull from these.
- ASC setting: HST Pathways, SIS Complete, AmkAI, Provation. See ASC EHRs for PA.
How Flexbone handles MSK PA
For an orthopedic or interventional pain practice, Flexbone deploys three agents. The document agent assembles the conservative-therapy timeline, imaging summary, and functional measures from the chart. The browser agent operates eviCore, Carelon, and payer portals. The voice agent handles peer-to-peer scheduling and phone-only payer lines. See the full workflow at PA workflow guide and the platform at prior authorization automation.
Conservative-therapy documentation is 60 percent of the PA denial reason in MSK. The AI pulls every PT note, injection date, medication trial, and imaging report and builds the timeline into the PA packet before first submission. That moves denials from documentation to legitimate clinical disagreement, which is much smaller in volume.