Shoulder Replacement Surgery Form

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Shoulder Replacement Surgery Medical Guideline

Service: Shoulder Replacement Surgery (Shoulder Arthroplasty, Shoulder Hemi- arthroplasty, Reverse Shoulder Arthroplasty, Arthroplasty Revision or Replacement, Shoulder Resurfacing)

PUM 250-0031-1812

Medical Guideline Committee Approval Q3-2025 Effective Date 03/01/2026

Related Medical Guidelines:

• Non-covered Services and Procedures medical guideline

Coverage for shoulder replacement surgery may vary across plans. Refer to the member’s benefit plan document for coverage details.

Description:

This medical guideline addresses the following surgical procedures: • Total shoulder arthroplasty (total shoulder replacement) • Shoulder hemi-arthroplasty
• Reverse shoulder arthroplasty
• Revision arthroplasty / Replacement of shoulder arthroplasty prosthesis • Shoulder resurfacing (see Limitations of Coverage)

Indications of Coverage:

A. Elective total shoulder arthroplasty (total shoulder replacement) or elective shoulder hemi-arthroplasty is considered medically necessary for an individual with advanced degenerative joint disease of the shoulder with joint space narrowing when all of the following (1 through 3) are met:

1. Radiographic or advanced imaging demonstrates any of the following: Flattened glenoid, glenoid sclerosis, glenoid osteophytes, cystic changes of humeral head, or irregular surfaces of joint.

2. Shoulder pain or decreased shoulder/upper extremity function that has interfered with the individual’s ability to perform activities of daily living for at least 3 months.

3. A trial of at least two weeks of provider-directed conservative management has failed to improve upper extremity/shoulder symptoms or function. Conservative measures must include anti-inflammatory or analgesic medication, unless contraindicated, and

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may include activity modification, bracing, sling use, or other provider-directed interventions.

B. Total shoulder arthroplasty (total shoulder replacement) or Shoulder Hemiarthroplasty are considered medically necessary in any of the following circumstances:

1. Confirmed malignancy (cancer) of glenohumeral joint or surrounding tissue.

2. Confirmed fracture, nonunion, malunion, or osteonecrosis of proximal humerus.

3. Failed reduction and internal fixation of proximal humeral fracture

4. Osteonecrosis of the humeral head

5. Fracture of the humerus

   C. Reverse Shoulder Arthroplasty is considered medically necessary in any of the following circumstances:

6. Very large or irreparable rotator cuff tear

7. Recurrent tear after rotator cuff repair

8. Failed total shoulder arthroplasty or hemi-arthroplasty.

9. Reconstruction necessary following tumor resection.

10. Shoulder fracture (or proximal humerus fracture) that is not repairable or cannot be reconstructed with other techniques.

11. Rheumatologic disease of the shoulder (rheumatoid arthritis or psoriatic arthritis) and ALL of the following:

    a. Shoulder pain or decreased shoulder/upper extremity function that has interfered with the individual’s ability to perform activities of daily living for at least 3 months.

    b. Minimum of 2 weeks of provider-directed conservative management has failed to improve symptoms. Conservative management may include any of the following: Analgesics, anti-inflammatories, DMARD (disease-modifying anti- rheumatic drug) (i.e., Enbrel, Humira), physical or occupational therapy, home exercise program, and/or activity modification, bracing, or sling use.

    c. Radiographic findings that show shoulder joint destruction or erosive disease.

12. Primary arthritis and deformities of the glenohumeral joint not amenable to a standard shoulder arthroplasty.

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8. Patient with shoulder arthroplasty and new or worsening rotator cuff tear leading to failure of the arthroplasty.

   D. Revision of total shoulder arthroplasty, revision of hemi-arthroplasty, or replacement of shoulder arthroplasty prosthesis is considered medically for any of the following:

9. Mechanical failure or fracture of the implant/periprosthetic bone

10. Infection of shoulder joint

11. Migration of the humeral head

12. Humeral prosthetic causing glenoid erosion.

13. Glenoid or humeral components unstable

14. Shoulder arthroplasty and new or worsening rotator cuff tear leading to failure of the arthroplasty.

    ****Patient specific instruments and/or custom implants/prostheses are considered not medically necessary for standard surgical services. However, if requested due to conditions such as severe bone loss, severe deformity, difficult surgical exposure, or revision arthroplasty, these will be reviewed individually on a case-by-case basis by the Medical Director.

    Limitations of Coverage:

    Benefit Limitations: Please note that in listing services or examples, when we say “this includes,” it is not our intent to limit the description to that specific list. When we do intend to limit a list of services or examples, we state specifically that the list “is limited to.”

    A. Review contract and endorsements for exclusions and prior authorization or benefit requirements.

    B. If used for a condition/diagnosis other than is listed in the Indications of Coverage, it will be considered experimental, investigational, and unproven to affect health outcomes.

    C. If used for a condition/diagnosis that is listed in the Indications of Coverage; but the criteria are not met, it will be considered not medically necessary.

    D. Total shoulder arthroplasty will be considered not medically necessary when performed in individuals with glenohumeral osteoarthritis who have an irreparable rotator cuff tear.

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E. Total shoulder arthroplasty, hemiarthroplasty, reverse shoulder arthroplasty or arthroplasty revision or replacement is considered not medically necessary in any of the following circumstances:

1. Active systemic infection or active infection of the joint
2. Progressive neurological disease
3. Charcot Arthropathy
4. Paralytic disorder of the shoulder such as irreversible brachial plexus palsy or spinal cord injury.

5. Use of a prosthetic device comprised of a material to which the individual has a known allergy or hypersensitivity.

   F. All of the following will be considered experimental, investigational, and unproven:

6. Sidus Stem-Free Shoulder System
7. Home continuous passive motion devices
8. Home use of pneumatic compression devices for prevention of deep vein thrombosis after shoulder surgery for an individual who is able to ambulate.
9. Acellular dermal extracellular matrix for shoulder capsular reconstruction
10. Use of a device/prosthetic that is not Food and Drug Administration (FDA) approved for the specific procedure/use.
11. Viscosupplementation, hyaluronic acid injections (including, but not limited to Orthovisc®, Synvisc®)
12. Stem cell therapy, stem cell injections
13. Peripheral nerve block or ablation
14. Platelet-rich plasma injection(s)
15. Bone marrow aspirate concentrate (BMAC) injection/treatment
16. Microfragmented adipose tissue (MFAT) injection/treatment (such as, but not limited to Lipogems®)
17. Platelet Lysate (PL)

18. Intraoperative surgical navigation or robotic assistance for shoulder arthroplasty are considered integral to the surgical procedure.

    G. Shoulder joint resurfacing, including total, hemi or partial resurfacing, is considered experimental, investigational or unproven.

    H. The Health Plan follows National Correct Coding Initiative (NCCI) which states the shoulder is a single anatomical structure (see Reimbursement Policy 1009: NCCI Shoulder Reimbursement. See also, NCCI Manual, chapter 4, available at: https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html)

    I. Limited or extensive debridement is not separately billable/reimbursable when performed on the same joint, during the same encounter.

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Documentation Required:

• Standard Written Order (SWO), prescribed by a qualified healthcare provider concerning the member’s diagnosis.
• Medical record information (including continued need/use if applicable) and medical necessity. Office visit notes and other clinical documentation (e.g., imaging reports, physical examination notes, surgical history) as appropriate to demonstrate Indications of Coverage for the requested procedure are met. • Correct coding for the item/service that meets all the coding guidelines.

Disclaimer: This guideline is for informational purposes only and does not constitute medical advice, plan authorization, an explanation of benefits, or a guarantee of payment. Benefit plans vary in coverage and some plans may or may not provide coverage for all services listed in this guideline. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and federal law. Some benefit plans administered by the organization may not utilize Medical Affairs medical guideline in all their coverage determinations. Contact customer services as listed on the member card for specific plan, benefit, and network status information.

Medical guidelines are based on constantly changing medical science and are reviewed annually and subject to change. The organization uses tools developed by third parties, such as the evidence-based clinical guidelines developed by MCG to assist in administering health benefits. This medical guideline and MCG guidelines are intended to be used in conjunction with the independent professional medical judgment of a qualified health care provider. To obtain additional information about MCG, email medical.policies@wpsic.com. Coverage of all services is subject to medical necessity and services deemed experimental, investigational, and/or unproven are therefore not considered medically necessary under the terms of the clinical guidelines and will not be covered.

Shoulder replacement surgery is considered medically necessary only when indicated per the most current medical references and specialty society guidelines, such as MCG, NCCN, etc.

State mandates, laws or benchmark supersede this medical guideline.

Guideline Review History:

Implemented 01/01/20, 06/01/21, 06/01/22, 03/01/23, 03/01/24, 03/01/26 Medical Guideline Committee Approval 09/27/19, Correction of typo on 02/27/20, 02/25/21, 02/24/22, 02/23/23, 02/28/24, Q3 2025 Reviewed

02/27/20, 02/25/21, 02/24/22, 09/26/22-updated C. Reverse Shoulder Arthroplasty criteria, 02/23/23, 02/28/24, Q3 2025 Developed 09/27/19

Approved by the Medical Director

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Codes: The following codes for treatments and procedures applicable to this document are included below for informational purposes. Code Description 20985 COMPUTER-ASSISTED SURGICAL NAVIATIONAL PROCEDURE FOR MUSCULOSKELETAL PROCEDURES, IMAGE-LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 23334 REMOVAL OF PROSTHESIS, INCLUDES DEBRIDEMENT AND SYNOVECTOMY WHEN PERFORMED; HUMERAL OR GLENOID COMPONENT 23335 REMOVAL OF PROSTHESIS, INCLUDES DEBRIDEMENT AND SYNOVECTOMY WHEN PERFORMED; HUMERAL AND GLENOID COMPONENTS (EG, TOTAL SHOULDER) 23470 ARTHROPLASTY, GLENOHUMERAL JOINT; HEMIARTHROPLASTY 23472 ARTHROPLASTY, GLENOHUMERAL JOINT; TOTAL SHOULDER (GLENOID AND PROXIMAL HUMERAL REPLACEMENT (EG, TOTAL SHOULDER)) 23473 REVISION OF TOTAL SHOULDER ARTHROPLASTY, INCLUDING ALLOGRAFT WHEN PERFORMED; HUMERAL OR GLENOID COMPONENT 23474 REVISION OF TOTAL SHOULDER ARTHROPLASTY, INCLUDING ALLOGRAFT WHEN PERFORMED; HUMERAL AND GLENOID COMPONENT 0RRJ0J6 REPLACEMENT OF RIGHT SHOULDER JOINT WITH SYNTHETIC SUBSTITUTE, HUMERAL SURFACE, OPEN APPROACH 0RRJ0J7 REPLACEMENT OF RIGHT SHOULDER JOINT WITH SYNTHETIC SUBSTITUTE, GLENOID SURFACE, OPEN APPROACH 0RRJ0JZ REPLACEMENT OF RIGHT SHOULDER JOINT WITH SYNTHETIC SUBSTITUTE, OPEN APPROACH 0RRJ00Z REPLACEMENT OF RIGHT SHOULDER JOINT WITH REVERSE BALL AND SOCKET SYNTHETIC SUBSTITUTE, OPEN APPROACH 0RRK0J6 REPLACEMENT OF LEFT SHOULDER JOINT WITH SYNTHETIC SUBSTITUTE, HUMERAL SURFACE, OPEN APPROACH 0RRK0J7 REPLACEMENT OF LEFT SHOULDER JOINT WITH SYNTHETIC SUBSTITUTE, GLENOID SURFACE, OPEN APPROACH 0RRK0JZ REPLACMENT OF LEFT SHOULDER JOINT WITH SYNTHETIC SUBSTITUTE, OPEN APPROACH 0RRK00Z REPLACEMENT OF LEFT SHOULDER JOINT WITH REVERSE BALL AND SOCKET SYNTHETIC SUBSTITUTE, OPEN APPROACH ORPJOJZ REVOMAL OF SYNTHETIC SUBSTITUTE FROM RIGHT SHOULDER JOINT, OPEN APPROACH

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ORPJ3JZ REMOVAL OF SYNTHETIC SUBSTITUTE FROM RIGHT SHOULDER JOINT, PERCUTANEOUS APPROACH ORPJ4JZ REMOVAL OF SYNTHETIC SUBSTITUTE FROM RIGHT SHOULDER JOINT, PERCUTANEOUS ENODOSCOPIC APPROACH ORPKOJZ REMOVAL OF SYNTHETIC SUBSTITUTE FROM LEFT SHOULDER JOINT, OPEN APPROACH ORPK3JZ REMOVAL OF SYNTHETIC SUBSTITUTE FROM LEFT SHOULDER, PERCUTANEOUS APPROACH ORPK4JZ REMOVAL OF SYNTHETIC SUBSTITUTE FROM LEFT SHOULDER, PERCUTANEOUS ENDOSCOPIC APPROACH ORWJOJZ REVISION OF SYNTHETIC SUBSTITUTE IN RIGHT SHOULDER JOINT, OPEN APPROACH ORWJ3JZ REVISION OF SYNTHETIC SUBSTITUTE IN RIGHT SHOULDER JOINT, PERCUTANEOUS APPROACH ORWJ4JZ REVISION OF SYNTHETIC SUBSTITUTE IN RIGHT SHOULDER JOINT, PERCUTANEOUS ENDOSCOPIC APPROACH ORWKOJZ REVISION OF SYNTHETIC SUBSTITUTE IN LEFT SHOULDER JOINT, OPEN APPROACH ORWK3JZ REVISION OF SYNTHETIC SUBSTITUTE IN LEFT SHOULDER JOINT, PERCUTANEOUS APPROACH ORWK4JZ REVISION OF SYNTHETIC SUBSTITUTE IN LEFT SHOULDER JOINT, PERCUTANEOUS ENDOSCOPIC APPROACH C1776 JOINT DEVICE (IMPLANTABLE)