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

Coverage is allowed for hemiarthroplasty, total shoulder arthroplasty, reverse total shoulder arthroplasty, revision arthroplasty, and shoulder arthrodesis for specified indications (e.g., advanced destructive arthritis, rotator cuff tear arthropathy, unreconstructible fractures, failed prior arthroplasty), while shoulder resurfacing is experimental/unproven and excluded; active infection, Charcot joint, deltoid deficiency (for reverse), paralytic shoulder (for hemi/total) and unstable medical comorbidities are not covered. Key requirements include documented function‑limiting pain and failure of ≥3 months of provider‑directed non‑surgical management (unless fracture or other stated exception), concordant radiographic/advanced imaging correlated with exam/symptoms, and procedure‑specific criteria (e.g., reverse requires functional deltoid and ≥90° passive elevation; revision requires documented prosthetic problems or >6 months unexplained pain), with full supporting documentation.