Humana Shoulder Arthroplasty - Medicare Advantage Form

Please refer to CMS website for the most current applicable CMS Online Manual System (IOMs)/National Coverage Determination (NCD)/ Local Coverage Determination (LCD)/Local Coverage Article (LCA)/ Transmittals.

There are no NCDs and/or LCDs for shoulder arthroplasty.

Description

Shoulder Arthroplasty

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The shoulder is made up of three bones: the humerus (upper arm bone), scapula (shoulder blade) and clavicle (collarbone), which together are called the glenohumeral (shoulder) joint. The ball or head of the humerus fits into a glenoid cavity (shallow socket) in the scapula and although it is often described as a ball-and-socket joint, the large humeral head articulates against and not within the small glenoid cavity.

Articular cartilage, a smooth substance that protects the bones and enables them to move easily, covers the ends of bones where they come together to form joints. A thin, smooth tissue called synovial membrane covers all remaining surfaces inside the glenohumeral joint and produces a small amount of synovial fluid that lubricates the joint and helps absorb stress during movement.

The muscles and tendons that surround the shoulder provide stability and support, which allows the shoulder to rotate through a greater range of motion and permits more mobility than any other joint in the body. The glenohumeral joint is capable of all types of joint movements including flexion, extension, abduction, adduction, circumduction and rotation. Glenohumeral joint functioning may be compromised by conditions including, but not limited to, avascular necrosis (AVN), inflammatory arthritis/rheumatoid arthritis, massive rotator cuff tear arthropathy, osteoarthritis (OA) and severe fractures.

In shoulder arthroplasty (replacement) surgery, the damaged parts of the shoulder are removed and replaced with artificial components called a prosthesis. The goals of shoulder arthroplasty are to reduce shoulder pain and restore joint mobility and function.

• Total shoulder arthroplasty (TSA), also referred to as anatomic total shoulder arthroplasty (aTSA), is a surgical procedure in which damaged bone and cartilage is removed from the glenohumeral joint replacing both the humeral head and glenoid with artificial components (prosthesis). The relative locations of the ball-and-socket components of the joints are maintained. The head of the humerus is replaced with a prosthetic ball and the glenoid surface is smoothed and replaced with a prosthetic socket.
• Reverse total shoulder arthroplasty (rTSA) is a surgical procedure in which damaged bone and cartilage is removed from the glenohumeral joint replacing both the humeral head and glenoid with artificial components (prosthesis). The relative locations of the ball and socket are switched, with the prosthetic ball attached to the scapula and the prosthetic socket is installed at the end of the humerus.
• Hemi-arthroplasty, also referred to as a partial joint arthroplasty, is a surgical procedure that involves replacing either the humeral head or the glenoid with a prosthesis.
• Revision shoulder arthroplasty is a surgical procedure that involves reconstruction or replacement of the prosthesis due to failure or complication of previous shoulder arthroplasty.
• Resurfacing arthroplasty, also referred to as resurfacing hemiarthroplasty, was designed as a possible alternative to conventional total shoulder replacement and reportedly replaces a smaller portion of the humeral head than conventional shoulder replacement surgery. Supposedly, this procedure is viewed as a potential alternative for an individual who is younger, physically active and has advanced or end stage degenerative joint disease or arthritis.

An example of an US Food & Drug Administration (FDA) approved device for shoulder resurfacing arthroplasty includes, but may not be limited to, the Copeland humeral resurfacing head.

Shoulder Arthroplasty

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Coverage Determination

Humana follows the CMS requirements that only allows coverage and payment for services that are reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the functioning of a malformed body member except as specifically allowed by Medicare.

In interpreting or supplementing the criteria above and in order to determine medical necessity consistently, Humana may consider the following criteria:

Shoulder Arthroplasty

The use of the criteria in this Medicare Advantage Medical Coverage Policy provides clinical benefits highly likely to outweigh any clinical harms. Services that do not meet the criteria above are not medically necessary and thus do not provide a clinical benefit. Medically unnecessary services carry risks of adverse outcomes and may interfere with the pursuit of other treatments which have demonstrated efficacy.

In interpreting or supplementing the criteria above and in order to determine medical necessity consistently, Humana may consider MCG Guidelines.

Coverage Limitations

US Government Publishing Office. Electronic code of federal regulations: part 411 – 42 CFR § 411.15 - Particular services excluded from coverage