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

eviCore covers hemi‑, total, reverse shoulder arthroplasty, revision arthroplasty, and arthrodesis when procedure‑specific criteria are met—generally function‑limiting pain for ≥3 months, failure of ≥3 months of provider‑directed non‑surgical care, and imaging/diagnostic confirmation of the listed structural pathology (reverse arthroplasty also requires a functional deltoid and ≥90° passive ROM; fracture scenarios may bypass conservative‑care requirements). Shoulder resurfacing is experimental/unproven and not covered; procedures are excluded for active infection, paralytic/deltoid deficiency, Charcot joint, uncontrolled medical conditions and other contraindications, and require detailed documentation (imaging, conservative treatment records, exam findings, prior operative reports).

"Shoulder arthrodesis is not medically necessary for Charcot joint."

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