156 Form

1

Medical Policy Shoulder Resurfacing Table of Contents • Policy: Commercial • Coding Information
• Information Pertaining to All Policies
• Policy: Medicare • Description
• References
• Authorization Information • Policy History

Policy Number: 156 BCBSA Reference Number: 7.01.119A (For Plan internal use only) NCD/LCD: NA Related Policies
• Hip Resurfacing, #046 • Reverse Shoulder Arthroplasty, #161 Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity Medicare Members: Managed Care HMO BlueSM and Medicare PPO BlueSM

Shoulder resurfacing, including total, hemi, or partial resurfacing is considered INVESTIGATIONAL. Prior Authorization Information Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.
Outpatient • For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient.

Outpatient Commercial Managed Care (HMO and POS) This is not a covered service.
Commercial PPO and Indemnity This is not a covered service. Medicare HMO BlueSM This is not a covered service. Medicare PPO BlueSM This is not a covered service. CPT Codes / HCPCS Codes / ICD Codes Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member.

2

Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable. CPT Codes There is no specific CPT code for this service.
ICD-9 Diagnosis Codes Investigational for all diagnoses. Description Resurfacing the shoulder joint is a method to treat painful shoulders without replacing the humeral head. Resurfacing of the humeral head can be accomplished with devices that provide either complete or partial coverage, and may be performed alone (hemi-resurfacing) or in combination with glenoid resurfacing (total shoulder resurfacing). The objective of resurfacing is to preserve the individual patient’s normal head-neck anatomy and bone stock.
Examples of prosthetic designs for shoulder resurfacing include the Mark prosthesis from Copeland™, the Extended Articulating Surface (EAS)™ Resurfacing Heads from Biomet Manufacturing, and Global CAP™ CTA Resurfacing Shoulder Humeral Head from DePuy. All shoulder resurfacing prosthetic systems are considered investigational regardless of the commercial name, the manufacturer or FDA approval status. Summary For shoulder resurfacing, questions remain about the stability and durability of these prostheses, as well as the effect of partial or total humeral resurfacing on the glenoid. Controlled studies are needed to evaluate the risks and benefits of hemi- and total shoulder resurfacing in comparison with hemi- and total shoulder replacement. At the present time, evidence is insufficient to permit conclusions concerning the effect of this procedure on health outcomes. Therefore, partial resurfacing, humeral resurfacing and total shoulder resurfacing are considered investigational. Policy History Date Action 11/2011-4/2012 Medical policy ICD 10 remediation: Formatting, editing and coding updates.
No changes to policy statements. 6/2011 Reviewed - Medical Policy Group – Orthopedics, Rehabilitation, Rheumatology. No changes to policy statements. 7/2010 Reviewed - Medical Policy Group – Orthopedics, Rehabilitation, Rheumatology. No changes to policy statements. 3/01/10 New policy, effective 3/01/10.
Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines References

3

1. Bryant D, Litchfield R, Sandow M et al. A comparison of pain, strength, range of motion, and functional outcomes after hemiarthroplasty and total shoulder arthroplasty in patients with osteoarthritis of the shoulder. A systematic review and meta-analysis. J Bone Joint Surg Am 2005; 87(9):1947-56.
2. Radnay CS, Setter KJ, Chambers L et al. Total shoulder replacement compared with humeral head replacement for the treatment of primary glenohumeral osteoarthritis: a systematic review. J Shoulder Elbow Surg 2007; 16(4):396-402.
3. Levy O, Copeland SA. Cementless surface replacement arthroplasty of the shoulder. 5- to 10-year results with the Copeland mark-2 prosthesis. J Bone Joint Surg Br 2001; 83(2):213-21.
4. Levy O, Copeland SA. Cementless surface replacement arthroplasty (Copeland CSRA) for osteoarthritis of the shoulder. J Shoulder Elbow Surg 2004; 13(3):266-71.
5. Levy O, Funk L, Sforza G et al. Copeland surface replacement arthroplasty of the shoulder in rheumatoid arthritis. J Bone Joint Surg Am 2004; 86-A(3):512-8.
6. Thomas SR, Wilson AJ, Chambler A et al. Outcome of Copeland surface replacement shoulder arthroplasty. J Shoulder Elbow Surg 2005; 14(5):485-91.
7. Buchner M, Eschbach N, Loew M. Comparison of the short-term functional results after surface replacement and total shoulder arthroplasty for osteoarthritis of the shoulder: a matched-pair analysis. Arch Orthop Trauma Surg 2008; 128(4):347-54.
8. Fuerst M, Fink B, Rüther W. The DUROM cup humeral surface replacement in patients with rheumatoid arthritis. J Bone Joint Surg Am 2007; 89(8):1756-62.
9. Uribe JW, Bemden AB. Partial humeral head resurfacing for osteonecrosis. J Shoulder Elbow Surg 2009 Jan 29 [Epub ahead of print].
10. ClinicalTrials.gov Available at: http://www.clinicaltrials.gov/ct2/results?term=shoulder+resurfacing Last viewed May 2009.