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

Covers hemi-, total, reverse total, revision shoulder arthroplasty and arthrodesis when imaging correlates with function‑limiting pain (generally ≥3 months) and there is failure of ≥3 months of provider‑directed non‑surgical care (exceptions for unreconstructable proximal humerus fractures and tumor reconstructions), with reverse TSA additionally requiring functional deltoid and ≥90° passive shoulder elevation and revision indicated for instability, loosening, infection, periprosthetic fracture or unexplained pain >6 months; shoulder resurfacing is considered experimental/investigational and not covered. Not covered when there is active local/systemic infection, paralytic shoulder disorders, uncontrolled/unstable medical conditions, Charcot joint (and deltoid deficiency for reverse TSA); documentation of symptom duration, prior conservative therapy, and correlating radiographic/advanced imaging (and specific functional findings) is required.

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