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

CMM‑318 covers hemiarthroplasty, total shoulder arthroplasty, reverse total shoulder arthroplasty (RTSA), revision arthroplasty, and shoulder arthrodesis when specific, procedure‑based criteria are met, while shoulder resurfacing is excluded as experimental and procedures are contraindicated with active infection, paralytic disorders, Charcot joint, uncontrolled comorbidities, and (for RTSA) deltoid deficiency. Key requirements generally include function‑limiting pain with failure of ≥3 months of provider‑directed non‑surgical care and confirmatory radiographic/advanced imaging (with exceptions for certain non‑repairable fractures and tumor reconstructions), RTSA additionally requires functional deltoid and ≥90° passive ROM, and revision/arthrodesis have specified indications such as instability, infection, aseptic loosening, or irreparable cuff/deltoid deficiency.

"Hemi-arthroplasty (replacement) is medically necessary 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-surgica..."