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

Hemi-, total and reverse shoulder arthroplasty (and revision/arthrodesis when specifically indicated) are covered for listed diagnoses (e.g., proximal humerus fracture, advanced degenerative disease, rotator cuff tear arthropathy, failed prior arthroplasty, unreconstructable fracture, tumor reconstruction), while shoulder resurfacing is considered experimental/unproven, reverse arthroplasty is investigational for indications beyond those listed, revision is not covered with persistent infection or poor bone quality, and arthrodesis is not covered for specified neuromuscular/Charcot/advanced-age conditions. Coverage requires documentation of at least six months of chronic severe disabling shoulder pain, loss of function affecting ADLs or employment, failure of non‑surgical management (minimum six weeks; six–eight weeks for arthrodesis), radiographic/advanced imaging correlating with exam/symptoms, no active joint/systemic infection, and procedure‑specific criteria (for reverse: functional deltoid, adequate bone stock and ≥90° passive shoulder elevation).