CMM-318: Shoulder Arthroplasty-Arthrodesis

Shoulder arthroplasty (hemi, total, reverse), selected revision arthroplasties, and arthrodesis are medically necessary only for specified indications (e.g., inadequate glenoid bone, avascular necrosis without glenoid involvement, rotator‑cuff tear arthropathy, unreconstructable fractures, certain revision indications), while shoulder resurfacing is experimental/unproven and procedures are excluded for active infection, paralytic disorders/Charcot joint, deltoid deficiency (for reverse TSA), or unstable medical comorbidities. Key requirements are conclusive imaging that correlates with symptoms, documented function‑limiting pain (typically ≥3 months for primary procedures; >6 months for unexplained pain before revision), failure of ≥3 months of provider‑directed non‑surgical management, and procedure‑specific documentation (e.g., deltoid function, pseudoparalysis, glenoid subluxation/Walch classification).

"Shoulder arthrodesis is considered medically necessary when ALL of the following criteria have been met:"