CurrentevicorePolicy CMM-318

Shoulder Arthroplasty/ Replacement/Resurfacing/Revision/Arthrodesis

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Medical necessity and coverage criteria for hemiarthroplasty, total shoulder arthroplasty, reverse total shoulder arthroplasty, resurfacing, revision, and arthrodesis for shoulder conditions under Cigna-administered plans as applied by eviCore.

Policy Summary

Payerevicore

PolicyShoulder Arthroplasty/ Replacement/Resurfacing/Revision/Arthrodesis

Policy CodePolicy CMM-318

Change TypeNo material change

Effective DateMar 7, 2026

Next Review Date

Key ActionObtain prior authorization when required by the benefit plan and submit supporting imaging plus documentation of failed conservative care.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥3 moMinimum non-surgical management (hemi)

6 moMinimum pain duration for revision

43%Arthrodesis complication rate

up to 25%Reported revision rate

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