CMM-315: Shoulder Surgery-Arthroscopic and Open Procedures

Covered: arthroscopic or open shoulder surgery is medically necessary only for the policy’s listed indications (e.g., fracture/tumor/infection, severe disease processes, diagnostic arthroscopy when MRI is inconclusive, rotator cuff tears, labral/biceps pathology, subacromial decompression when criteria met, capsular release/MUA and stabilization for instability); procedures outside those indications are not medically necessary and certain uses (e.g., isolated manipulation without rehab, some capsular releases/MUA) are investigational. Key requirements: documented loss of shoulder function affecting ADLs/employment, correlating physical exam findings and advanced imaging, exclusion of other diagnoses, and failure of procedure‑specific non‑surgical management timeframes (commonly 6–12 weeks up to 3 months—rotator cuff repair ≥8 weeks except acute complete tears; diagnostic arthroscopy ≥3 months of failed care; adhesive capsulitis ≥6 months of severe symptoms with ≥6 weeks combination therapy), and evidence of active rehabilitation when MUA is performed.