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

Shoulder arthroplasty (hemi, total, reverse), revision arthroplasty, and arthrodesis are covered for specific diagnoses (advanced degenerative/ inflammatory disease, rotator cuff tear arthropathy, avascular necrosis, irreparable proximal humerus/shoulder fractures, failed prior arthroplasty, etc.), while shoulder resurfacing is investigational and procedures are excluded for active infection, Charcot joint, paralytic disorders (and deltoid deficiency for reverse arthroplasty) and other specified contraindications. Coverage requires documented function‑limiting pain, failure of ≥3 months of provider‑directed non‑surgical management (except for non‑repairable fractures), corroborative imaging/advanced diagnostics and procedure‑specific criteria (e.g., functional deltoid and ≥90° passive ROM for reverse; >6 months unresponsive pain or mechanical failure for revision).

"Hemi-arthroplasty (replacement) is considered medically necessary when ALL of the following criteria have been met: Function-limiting pain (e."