CMM-315: Shoulder Surgery-Arthroscopic and Open Procedures

Arthroscopic and open shoulder procedures are medically necessary only when ALL procedure‑specific criteria are met — typically documented function‑limiting pain, objective exam deficits versus the contralateral side, corroborative advanced imaging, and failure of provider‑directed non‑surgical management — and are not covered if criteria are absent; certain interventions (e.g., standalone subacromial decompression, in‑office arthroscopy) are excluded or considered experimental. Required documentation includes duration/details of symptoms, specific exam findings, imaging reports, and conservative treatment records (usually ≥3 months; diagnostic arthroscopy and adhesive capsulitis ≥6 months), with limited exceptions for acute traumatic full‑thickness rotator cuff tears and acute locking from loose bodies.

"Labral repair/biceps tenodesis is considered not medically necessary for any other indication or condition beyond the listed criteria."