Total Shoulder Arthroplasty

Total shoulder arthroplasty (including reverse TSA) is covered for oncologic reconstruction after tumor resection, degenerative glenohumeral disease (OA, RA, osteonecrosis, post‑traumatic arthritis) with failed conservative care, massive irreparable rotator cuff tears with pseudo‑paralysis, revision RTSA after failed aTSA/HA, acute proximal humerus fractures not amenable to nonoperative care or fixation, and nonunion/malunion when criteria are met; procedures that do not meet these indications or are performed by uncredentialed providers are not covered. Key requirements include documented radiographic diagnosis and ≥12 weeks of moderate‑to‑severe pain or functional disability plus ≥12 weeks of unsuccessful conservative therapy (or documentation why conservative therapy is not reasonable); for MIRCTs the 12‑week trial must include supervised physical therapy and documented pseudo‑paralysis (active elevation <90°), and supporting MRI/arthroscopy, imaging/operative/pathology reports and provider credentialing/privileging must be in the record.