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

EviCore covers hemiarthroplasty, total shoulder arthroplasty, reverse total shoulder arthroplasty (RTSA), revision arthroplasty, and shoulder arthrodesis for clearly specified diagnoses (e.g., arthritis with inadequate glenoid bone or AVN, proximal humerus fractures not amenable to fixation, irreparable rotator cuff/rotator cuff tear arthropathy, Walch B2/B3/C glenoid retroversion, posterior humeral head subluxation >50%, tumor/reconstruction, and defined revision indications) while excluding shoulder resurfacing as experimental and denying procedures with active infection, Charcot joint, deltoid deficiency for RTSA, paralytic shoulder disorders, or unstable/uncontrolled medical conditions. Coverage requires corroborating radiographic/advanced imaging and physical exam consistent with the diagnosis, documentation of function‑limiting pain and failure of provider‑directed non‑surgical management for ≥3 months (≥6 months for unexplained revision pain), CT confirmation for Walch B2/B3/C retroversion, imaging confirmation of >50% subluxation when applicable, and demonstrated deltoid function for RTSA.