CMM-315: Shoulder Surgery-Arthroscopic and Open Procedures

Covers arthroscopic and open shoulder procedures (e.g., diagnostic arthroscopy, loose/foreign body removal, synovectomy, debridement, rotator cuff repair, distal clavicle excision) only when procedure‑specific objective imaging and plain radiographs as required, side‑to‑side physical exam findings, documented function‑limiting symptoms, and failure of provider‑directed non‑surgical management for the specified durations are met (examples: diagnostic arthroscopy needs inconclusive MRI/CT + ≥6 months function‑limiting pain and ≥3 months non‑surgical failure; loose body removal needs imaging showing a loose body + pain/mechanical symptoms and usually ≥3 months non‑surgical failure or immediate treatment if locking; rotator cuff repair needs MRI/CT evidence of Grade 2/3 partial or full‑thickness tear + exam findings and generally ≥3 months non‑surgical care except for acute traumatic full‑thickness tears without chronic changes). Excludes or considers experimental/not medically necessary many techniques (e.g., in‑office diagnostic arthroscopy such as Mi‑Eye/VisionScope, superior capsular reconstruction, coracoplasty/subcoracoid decompression, labral repair, biceps tenodesis, instability surgeries, standalone subacromial decompression, isolated MUA); all approvals require documentation correlating imaging, exam, symptom duration, and prior conservative care.