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

Covers hemiarthroplasty, total shoulder arthroplasty, reverse total shoulder arthroplasty, revision arthroplasty, and arthrodesis when procedure‑specific indications are met, but excludes shoulder resurfacing (investigational) and procedures with absolute contraindications such as active local/systemic infection, paralytic shoulder disorders, Charcot joint, deltoid deficiency for reverse arthroplasty, or uncontrolled/unstable medical comorbidities. Requires documentation of function‑limiting pain (generally ≥3 months) and failure of ≥3 months of provider‑directed non‑surgical management (exceptions for certain unreconstructable fractures), corroborating imaging/advanced diagnostics, and adherence to procedure‑specific criteria (e.g., marked joint‑space narrowing plus other radiographic signs for total shoulder, functional deltoid and ≥90° passive elevation for reverse, and specified indications for revision and arthrodesis).

"Hemi-arthroplasty (replacement) when ALL of the following are met: function-limiting pain for at least 3 months; failure of at least 3 months of provider-directed non-surgical management; radiograp..."