CMM-315: Shoulder Surgery-Arthroscopic and Open Procedures

Arthroscopic and open shoulder procedures (e.g., diagnostic arthroscopy, loose body removal, synovectomy, debridement, rotator cuff repair) are medically necessary only when detailed, procedure‑specific criteria are met and are not covered if criteria are unmet; in‑office diagnostic arthroscopy, superior capsular reconstruction, and coracoplasty/subcoracoid decompression are considered experimental/investigational and not supported. Key requirements include documented function‑limiting pain of specified duration, detailed physical exam findings versus the non‑involved side, imaging that correlates with symptoms, and failure of provider‑directed non‑surgical management (generally ≥3 months unless procedure‑specific exceptions apply); subacromial decompression cannot be performed as a standalone procedure and MUA requires concurrent active rehabilitation.

"Labral repair/biceps tenodesis is considered not medically necessary for any other indication or condition (i."