Appropriateness of prior authorization requirements for total shoulder arthroplasty: a systematic review

Total shoulder arthroplasty has become increasingly utilized for managing glenohumeral osteoarthritis (GHOA), with procedure rates expected to rise. Consequently, there has been a surge in prior authorization (PA) requests for total shoulder arthroplasty, imposing a substantial administrative burden and highlighting the need for physician advocates to challenge the current PA system. A notable PA requirement is preoperative physical therapy (PT), a treatment modality for GHOA that has not been extensively studied and is not endorsed by the American Academy of Orthopeadic Surgery as necessary for the treatment for GHOA. We conducted a systematic literature search using PubMed, Embase, and Medline, adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Our search focused on studies with level IV evidence or higher that examined the efficacy preoperative PT for patients with GHOA. We found 210 studies of which 3 met our inclusion criteria. Our results were mixed, with 2 of the 3 studies supporting the use of preoperative PT. Only one study employed a randomized controlled trial design, underscoring the need for more high-quality studies in this area. Our findings suggest that there is limited evidence for the benefit of preoperative PT in GHOA. This contradicts the current PA requirements which require patients to undergo preoperative PT to receive coverage for treatment. This review highlights the need for physician engagement in advocacy efforts to challenge these current requirements and improve patient care.