CMM-315: Shoulder Surgery-Arthroscopic and Open Procedures

This policy deems a range of arthroscopic and open shoulder procedures medically necessary only when detailed, procedure‑specific criteria are met (diagnostic arthroscopy, loose/foreign body removal, synovectomy, debridement, rotator cuff repair, distal clavicle excision, labral repair/biceps tenodesis, instability procedures, arthroscopic capsular release/MUA), while in‑office diagnostic arthroscopy systems and superior capsular reconstruction are experimental/investigational and subacromial decompression is allowed only as an add‑on, not as a standalone. Key requirements include documented function‑limiting pain, specific objective exam findings and imaging that correlate with symptoms, exclusion of alternative diagnoses, and failure of provider‑directed non‑surgical management (generally ≥3 months; some procedures require ≥6 months or have specific exceptions such as acute locking loose bodies or certain traumatic rotator cuff tears).

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