CMM-315: Shoulder Surgery-Arthroscopic and Open Procedures

This guideline authorizes specific arthroscopic and open shoulder procedures only when procedure‑specific criteria are met and otherwise deems them not medically necessary (notably subacromial decompression/acromioplasty is not approved as a stand‑alone procedure, and in‑office diagnostic arthroscopy devices and superior capsular reconstruction are considered experimental/unproven and excluded). Key requirements include documented function‑limiting pain with specified symptom duration (commonly ≥3 months conservative care or ≥6 months for some indications), failure of provider‑directed non‑surgical management, required physical exam deficits versus the non‑involved side, correlating advanced imaging (or specified acute exceptions), and documentation excluding other pathologies.

"General: Shoulder arthroscopic or open surgical procedures may be considered medically necessary when surgery is being performed for fracture, tumor, infection or foreign body that has led to or wi..."