CMM-318: Shoulder Arthroplasty/Replacement/Resurfacing/ Revision/Arthrodesis

Covers hemiarthroplasty, total shoulder arthroplasty, reverse total shoulder arthroplasty, revision arthroplasty, and shoulder arthrodesis when procedure‑specific indications are met; shoulder resurfacing is considered experimental/unproven, and procedures are excluded when there is active local/systemic infection, paralytic shoulder disorders (or deltoid deficiency for reverse arthroplasty), Charcot joint, or uncontrolled/unstable comorbidities. Key requirements generally include documented function‑limiting pain with failure of ≥3 months of provider‑directed non‑surgical management plus corroborative imaging/diagnostics (fracture indications may waive duration/ conservative‑therapy requirements), with additional specifics such as functional deltoid and ≥90° passive elevation for reverse arthroplasty and defined mechanical/infectious findings or >6 months unexplained pain for revision.

"General statement: determination of medical necessity is made case-by-case (i."