CMM-315: Shoulder Surgery-Arthroscopic and Open Procedures

The policy deems a range of arthroscopic and open shoulder surgeries (e.g., diagnostic arthroscopy, loose body removal, synovectomy, debridement, rotator cuff repair, distal clavicle excision/subacromial decompression, labral repair, biceps tenodesis, instability procedures, capsular release/MUA) medically necessary only when there are function‑limiting symptoms with objective exam deficits versus the non‑involved side, appropriate imaging, exclusion of alternative diagnoses, and documented failure of provider‑directed non‑surgical management for specified durations (generally ≥3 months, ≥6 months for diagnostic arthroscopy/capsular release, with limited exceptions for acute injuries). Procedures excluded or considered experimental/investigational (not covered) include in‑office diagnostic arthroscopy, superior capsular reconstruction, and coracoplasty/subcoracoid decompression; arthroscopic subacromial decompression is not covered as a standalone add‑on, and MUA without an active rehabilitation program is not medically necessary.