CMM-315: Shoulder Surgery-Arthroscopic and Open Procedures

Covers arthroscopic and open shoulder procedures (e.g., diagnostic arthroscopy, loose‑body removal, synovectomy, debridement, rotator cuff repair, distal clavicle excision) only when strict, procedure‑specific criteria are met and deems procedures not meeting those criteria not medically necessary; in‑office diagnostic arthroscopy is investigational and subacromial decompression/acromioplasty is not approved as a stand‑alone procedure. Key requirements include documented function‑limiting pain with specified durations (generally ≥3 months of failed provider‑directed non‑surgical management or ≥6 months for some indications), objective side‑to‑side exam findings, advanced imaging that correlates with symptoms (or is inconclusive for diagnostic arthroscopy), exclusion of other pathologies, and limited acute/trauma exceptions.

"Synovectomy is considered not medically necessary for any other indication or condition beyond the specified criteria."