Humana Shoulder Arthroplasty Form

Description

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.

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Shoulder Arthroplasty

Effective Date: 08/24/2023
Revision Date: 08/24/2023
Review Date: 08/24/2023
Policy Number: HUM-0592-005

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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

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.

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Shoulder Arthroplasty

Effective Date: 08/24/2023
Revision Date: 08/24/2023
Review Date: 08/24/2023
Policy Number: HUM-0592-005

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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

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. (Refer to Coverage Limitations section.)

Coverage Determination

Total Shoulder Arthroplasty (TSA)

Humana members may be eligible under the Plan for TSA when the following criteria are met:

• Absence of contraindications; AND
• Adequate glenoid bone stock to support implantation of glenoid prosthesis; AND
• Individual who is a smoker or nicotine user is provided assistance in developing a plan for cessation (quitting) that includes pharmacotherapy (eg, bupropion, varenicline) and/or referral to a smoking cessation program prior to the surgical procedure; AND
• Intact rotator cuff; AND
• The prosthesis is FDA approved;

AND one of the following:

• Avascular necrosis of humeral head with collapse in the presence of stage 4 osteoarthritis; OR
• Glenoid bone degeneration with anterior or posterior subluxation; OR
• Proximal humerus fracture malunion or nonunion; OR
• Reconstruction after tumor resection; OR
• Revision of failed hemi-arthroplasty; OR
• Glenohumeral joint degeneration (AVN, inflammatory arthritis/rheumatoid arthritis, OA or posttraumatic arthritis);

AND

• Documentation of disabling pain and functional disability (loss of shoulder function which interferes with the ability to carry out age-appropriate activities of daily living [ADL]); AND
• Documentation including radiological interpretation (eg, shoulder joint destruction, severe joint space narrowing and/or cystic changes) and report for bony pathology (eg, routine radiographs) or soft tissue pathology (eg, computerized tomography [CT] scan and/or magnetic resonance imaging [MRI]); AND
• Failure of at least 3 months of conservative treatment under the direction of a healthcare professional, which includes:
  • Activity/lifestyle modifications; AND
  • Intra-articular injections when medically appropriate and not contraindicated. Intra-articular steroid injections should be avoided 3 months prior to TSA; AND
  • Medications (eg, nonsteroidal anti-inflammatory drugs (NSAIDs) or non-narcotic analgesics) when medically appropriate and not contraindicated; AND
  • Physical therapy including home exercise program (HEP) (for information regarding coverage determination/ limitations, please refer to Physical Therapy and Occupational Therapy Medical Coverage Policy)

Reverse Total Shoulder Arthroplasty (rTSA)

Shoulder Arthroplasty Effective Date: 08/24/2023
Revision Date: 08/24/2023
Review Date: 08/24/2023
Policy Number: HUM-0592-005
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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Humana members may be eligible under the Plan for rTSA when the following criteria are met:

• Absence of contraindications; AND
• Adequate glenoid bone stock to support implantation of glenoid prosthesis; AND
• Individual who is a smoker or nicotine user is provided assistance in developing a plan for cessation that includes pharmacotherapy (eg, bupropion, varenicline) and/or referral to a smoking cessation program prior to the surgical procedure; AND
• Intact deltoid; AND
• The prosthesis is FDA approved;

AND one of the following:

• Avascular necrosis of humeral head with collapse in the presence of stage 4 osteoarthritis; OR
• Failed TSA or hemiarthroplasty with irreparable rotator cuff tear; OR
• Glenohumeral arthritis with massive irreparable rotator cuff tear (tears 5 cm or greater in size and involve at least both the supraspinatus and infraspinatus muscle components of the rotator cuff); OR
• Massive irreparable rotator cuff tear (tears 5 cm or greater in size and involve at least both the supraspinatus and infraspinatus muscle components of the rotator cuff) with pseudoparalysis; OR
• Nonfunctional rotator cuff; OR
• OA with posterior glenohumeral subluxation; OR
• Reconstruction after tumor resection; OR
• Rotator cuff arthropathy; OR
• Three- or four-part proximal humerus fracture; OR
• Glenohumeral joint degeneration (AVN, inflammatory arthritis/rheumatoid arthritis, OA or posttraumatic arthritis); AND

Documentation of disabling pain and functional disability (loss of shoulder function which interferes with the ability to carry out age-appropriate ADLs); AND

Documentation including radiological interpretation (eg, shoulder joint destruction, severe joint space narrowing and/or cystic changes) and report for bony pathology (eg, routine radiographs) or soft tissue pathology (eg, CT scan and/or MRI); AND

Failure of at least 3 months of conservative treatment under the direction of a healthcare professional, which includes:

• Activity/lifestyle modifications; AND
• Intra-articular injections when medically appropriate and not contraindicated. Intra-articular steroid injections should be avoided 3 months prior to rTSA; AND
• Medications (eg, NSAID or non-narcotic analgesics) when medically appropriate and not contraindicated; AND
• Physical therapy including home exercise program (HEP) (for information regarding coverage determination/limitations, please refer to Physical Therapy and Occupational Therapy Medical Coverage Policy)

Shoulder Arthroplasty Effective Date: 08/24/2023
Revision Date: 08/24/2023
Review Date: 08/24/2023
Policy Number: HUM-0592-005
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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Hemi-arthroplasty

Shoulder Arthroplasty Effective Date: 08/24/2023
Revision Date: 08/24/2023
Review Date: 08/24/2023
Policy Number: HUM-0592-005
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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Hemi-arthroplasty

Humana members may be eligible under the Plan for hemi-arthroplasty when the following criteria are met:

• Absence of contraindications; AND
• Adequate humeral bone stock to support implantation of humeral prosthesis; AND
• Individual who is a smoker or nicotine user is provided assistance in developing a plan for cessation that includes pharmacotherapy (eg, bupropion, varenicline) and/or referral to a smoking cessation program prior to the surgical procedure; AND
• Intact rotator cuff; AND
• Pathologic condition (eg, AVN, OA) is on the humeral head; AND
• The prosthesis is FDA approved;

AND one of the following:

• Anatomic humeral neck fracture; OR
• Avascular necrosis of humeral head with collapse in the presence of stage 4 osteoarthritis; OR
• Fracture of humeral head (eg, impaction fracture) with involvement of greater than 40% of the articular surface; OR
• Humeral head splitting fracture; OR
• Proximal humerus fracture with failed open reduction and internal fixation (ORIF); OR
• Three- or four-part proximal humerus fracture; OR
• Glenohumeral joint degeneration (AVN, inflammatory arthritis/rheumatoid arthritis, OA or posttraumatic arthritis); AND

Documentation of disabling pain and functional disability (loss of shoulder function which interferes with the ability to carry out age-appropriate ADLs); AND

Documentation including radiological interpretation (eg, inadequate glenoid bone stock, shoulder joint destruction, severe joint space narrowing and/or cystic changes,) and report for bony pathology (eg, routine radiographs) or soft tissue pathology (eg, CT scan and/or MRI); AND

Failure of at least 3 months of conservative treatment under the direction of a healthcare professional, which includes:

• Activity/lifestyle modifications; AND
• Intra-articular injections when medically appropriate and not contraindicated. Intra-articular steroid injections should be avoided 3 months prior to hemi-arthroplasty; AND
• Medications (eg, NSAIDs or non-narcotic analgesics) when medically appropriate and not contraindicated; AND
• Physical therapy including home exercise program (HEP) (for information regarding coverage determination/limitations, please refer to Physical Therapy and Occupational Therapy Medical Coverage Policy)

Revision Shoulder Arthroplasty

Shoulder Arthroplasty Effective Date: 08/24/2023
Revision Date: 08/24/2023
Review Date: 08/24/2023
Policy Number: HUM-0592-005
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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

• bupropion, varenicline) and/or referral to a smoking cessation program prior to the surgical procedure; AND
• The prosthesis is FDA approved;

AND one of the following:

• Aseptic or septic loosening of the components (prosthesis); OR
• Failed hemi or TSA; OR
• Instability of the glenoid or humeral component; OR
• Periprosthetic fracture; OR
• Periprosthetic infection; OR
• Recurrent prosthetic dislocation; OR
• Unexplained disabling pain and functional disability (loss of shoulder function which interferes with the ability to carry out age-appropriate ADLs)

Coverage Limitations

Humana members may NOT be eligible under the Plan for a shoulder arthroplasty for any indications other than those listed above including, but may not be limited to, the following contraindications:

• Active or chronic infection, systemic or infection localized to the operative site; OR
• Allergy or sensitivity to the implant materials (eg, chromium, cobalt, hydroxyapatite, molybdenum, polyethylene, stainless steel or titanium); OR
• Deltoid deficiency (inactive or loss of the deltoid) (eg, axillary nerve palsy); OR
• Inadequate bone stock to support implantation of prosthesis; OR
• Neuropathic (Charcot) arthropathy of the shoulder; OR
• Paralytic disorders of the shoulder (eg, irreversible brachial plexus injury, neuromuscular disease or spinal cord injury)

This is considered experimental/investigational as it is not identified as widely used and generally accepted for any other proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.

Humana members may NOT be eligible under the Plan for shoulder joint resurfacing. This is considered experimental/investigational as it is not identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.

Additional information about shoulder conditions may be found from the following websites:

Background

• American Academy of Orthopaedic Surgeons
• National Library of Medicine

Medical Alternatives

Physician consultation is advised to make an informed decision based on an individual's health needs.

Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.

Shoulder Arthroplasty Effective Date: 08/24/2023
Revision Date: 08/24/2023
Review Date: 08/24/2023
Policy Number: HUM-0592-005
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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.