CMM-315: Shoulder Surgery-Arthroscopic and Open Procedures

Arthroscopic or open shoulder procedures are covered only for fracture/tumor/infection/foreign body or when procedure‑specific criteria are met—generally function‑limiting pain (typically ≥3–6 months), specified abnormal physical exam findings, failure of provider‑directed non‑surgical management (usually ≥3 months), and correlating advanced imaging—and many listed procedures are considered not medically necessary if criteria are not met. Key requirements include documentation of symptom duration and functional limitation, failed conservative therapy, specific positive exam tests, and appropriate imaging (with exceptions for certain acute traumatic tears and isolated distal clavicle excision); in‑office diagnostic arthroscopy, superior capsular reconstruction, and coracoplasty/subcoracoid decompression are considered experimental/investigational.

"Shoulder arthroscopic or open surgical procedures may be considered medically necessary for individuals when surgery is being performed for fracture, tumor, infection, or foreign body that has led ..."