CMM-315: Shoulder Surgery-Arthroscopic and Open Procedures

Covered only when specific criteria are met: shoulder arthroscopic/open procedures (e.g., diagnostic arthroscopy, loose/foreign body removal, synovectomy, debridement, rotator cuff repair, or surgery for fracture/tumor/infection) are medically necessary only with required imaging (MRI/CT/arthrogram or radiographs as specified), documented physical‑exam deficits compared to the noninvolved side, function‑limiting symptoms (often ≥6 months for some procedures) and failure of provider‑directed non‑surgical management (usually ≥3 months). Excluded or experimental: superior capsular reconstruction, coracoplasty/subcoracoid decompression, arthroscopic subacromial decompression/acromioplasty as a standalone, labral repair, biceps tenodesis, most instability procedures, and any surgery that does not meet the above documentation requirements (with limited exceptions for acute trauma, acute locking from a loose body, and isolated distal clavicle excision).

"Arthroscopic or Open Procedure for Fracture, Tumor, Infection, or Foreign Body: Shoulder arthroscopic or open surgical procedures may be considered medically necessary for individuals when surgery ..."