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CurrentevicorePolicy CMM-315

Shoulder Surgery Arthroscopic and Open Procedures

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Clinical coverage policy for arthroscopic and open shoulder surgeries (including procedures for rotator cuff, labrum, impingement, instability, fractures, tumors, infection, and foreign bodies) used by Cigna plans administered by eviCore; intended to guide medical necessity determinations for providers and payers.

Policy Summary

Payerevicore

PolicyShoulder Surgery Arthroscopic and Open Procedures

Policy CodePolicy CMM-315

Change TypeNo material changes

Effective DateAug 4, 2026

Next Review DateN/A

Key ActionObtain prior authorization with imaging, documented exam findings, and at least a 3‑month trial of provider-directed non-surgical management when required.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 of 7Part

v1.0.2026Version

3 monthsNon-surgical trial

6 monthsDiagnostic arthroscopy symptom duration

NMNIn‑office arthroscopy

EIUSuperior capsule reconstruction

Medical Necessity - Coverage Criteria

inv-01: Procedures for Fracture, Tumor, Infection, or Foreign Body

Arthroscopic or open shoulder surgery for specific indications

Fracture/Tumor/Infection/Foreign body: Arthroscopic or open shoulder surgery may be considered medically necessary when surgery is being performed for fracture, tumor, infection, or foreign body that has led to, or will likely lead to, progressive destruction.N/A

From CMM.JT.IN.315

inv-02: Fracture/Tumor/Infection/Foreign Body

Arthroscopic or open shoulder surgery for fracture, tumor, infection, or foreign body

Fracture/Tumor/Infection/Foreign Body Surgery: Arthroscopic or open shoulder surgery may be considered medically necessary when surgery is being performed for fracture, tumor, infection, or foreign body that has led to, or will likely lead to, progressive destruction.

Policy Summary

Payerevicore

PolicyShoulder Surgery Arthroscopic and Open Procedures

Policy CodePolicy CMM-315

Change TypeNo material changes

Effective DateAug 4, 2026

Next Review DateN/A

Key ActionObtain prior authorization with imaging, documented exam findings, and at least a 3‑month trial of provider-directed non-surgical management when required.

SourceLink

On This Page

inv-03: Diagnostic Arthroscopy

Diagnostic arthroscopy is considered medically necessary as a stand-alone procedure when ALL of the following criteria have been met:

Diagnostic Arthroscopy Criteria: MRI or CT is inconclusive for internal derangement/pathology; Physical exam demonstrates ALL of: functionally-limited range of motion (active or passive), measurable loss of strength, positive Neer or Hawkins-Kennedy impingement test (as compared to the noninvolved side); Symptoms include function-limiting pain for at least six (6) months; Failure of provider-directed non-surgical management for at least three (3) months; Other potential pathological conditions have been excluded (e.g., fracture, thoracic outlet syndrome, brachial plexus disorders, referred neck pain, cervical radiculopathy, and advanced glenohumeral osteoarthritis).symptoms >= 6 months; non-surgical mgmt >= 3 months

inv-04: Loose Body/Foreign Body Removal

Loose body or foreign body removal is considered medically necessary when ALL of the following criteria have been met:

Loose/Foreign Body Removal Criteria: MRI or CT shows findings of a loose body or foreign body within the shoulder joint; Symptoms include BOTH function-limiting pain and mechanical symptoms (painful locking, clicking, catching, or popping); Failure of provider-directed non-surgical management for at least three (3) months (exception: not required if the loose body/foreign body causes acute restriction/locking); Other potential pathological conditions have been excluded (e.g., fracture, thoracic outlet syndrome, brachial plexus disorders, referred neck pain, cervical radiculopathy, and advanced glenohumeral osteoarthritis).non-surgical mgmt >= 3 months (unless acute locking)

inv-05: Synovectomy

Synovectomy (partial or complete) is considered medically necessary when ALL of the following criteria have been met:

Synovectomy Criteria: MRI or CT arthrogram shows findings of synovitis; Presence of ANY qualifying conditions (e.g., inflammatory arthritis, pigmented villonodular synovitis, synovial chondromatosis, Lyme synovitis, hemophilia, hemochromatosis, non-specific synovitis, recurrent hemarthrosis); Physical exam demonstrates functionally-limited range of motion; Symptoms include function-limiting pain; Failure of provider-directed non-surgical management for at least three (3) months; Other potential pathological conditions have been excluded (e.g., fracture, thoracic outlet syndrome, brachial plexus disorders, referred neck pain, cervical radiculopathy, and advanced glenohumeral osteoarthritis).non-surgical mgmt >= 3 months

List of qualifying synovitis-related conditions required

inv-06: Debridement

Debridement (limited or extensive) is considered medically necessary when ALL of the following criteria have been met:

Debridement Criteria: MRI or CT shows underlying pathology that correlates with the individual's reported symptoms and physical exam; Physical exam demonstrates BOTH (compared to the noninvolved side) EITHER functionally-limited range of motion OR measurable loss of strength, AND ANY listed positive orthopedic tests/signs (e.g., drop arm, painful arc, Jobe/empty can, external rotation lag, lift-off, belly press, cross body adduction, resisted AC extension, Neer, Hawkins-Kennedy, O'Brien, biceps load, clunk, anterior slide, compression rotation, Speed's, upper cut, Yergason's, proximal biceps tenderness, modified dynamic labral shear); Symptoms include function-limiting pain; Failure of provider-directed non-surgical management for at least three (3) months; Other potential pathological conditions have been excluded (e.g., fracture, thoracic outlet syndrome, brachial plexus disorders, referred neck pain, cervical radiculopathy, and advanced glenohumeral osteoarthritis).non-surgical mgmt >= 3 months

Extensive list of specific orthopedic tests required to correlate

inv-07: Rotator Cuff Repair

Rotator cuff repair is considered medically necessary when ALL of the following criteria have been met:

Rotator cuff repair criteria: Imaging (MRI or CT) shows either Grade 2 or 3 partial-thickness rotator cuff tear (Ellman) OR a full-thickness rotator cuff tear (Cofield); Physical exam demonstrates (compared to the noninvolved side) EITHER functionally-limited range of motion OR measurable loss of rotator cuff strength, plus ANY listed positive orthopedic tests/signs (e.g., drop arm, painful arc, Jobe, external rotation lag, lift-off, Neer, Hawkins-Kennedy, Hornblower, Yocum, etc.); Symptoms include function-limiting pain; Failure of provider-directed non-surgical management for at least three (3) months (exception: discrete traumatic acute full-thickness tear without pre-existing chronic tear does not require 3-month trial).

Fatty infiltration or muscle atrophy on imaging indicates pre-existing chronic tear and removes the trauma exception; other pathologies must be excluded.

inv-08: Distal Clavicle Excision

Distal clavicle excision is considered medically necessary when ALL of the following criteria have been met:

Distal clavicle excision criteria: Imaging shows BOTH plain radiographs with pathology in the subacromial space and/or AC joint AND MRI or CT findings that correlate with the individual's reported symptoms and physical exam (exception: advanced imaging not required for isolated distal clavicle excision when not associated with subacromial decompression/acromioplasty); Physical exam demonstrates BOTH localized AC joint tenderness and ANY listed positive orthopedic tests/signs (e.g., cross body adduction, resisted AC joint extension); Symptoms include function-limiting pain; Failure of provider-directed non-surgical management for at least three (3) months; Other potential pathological conditions have been excluded (e.g., fracture, thoracic outlet syndrome, brachial plexus disorders, referred neck pain, cervical radiculopathy, and advanced glenohumeral osteoarthritis).

inv-09: Subacromial Decompression / Acromioplasty

Subacromial decompression/acromioplasty is considered medically necessary when ALL of the following criteria have been met:

Subacromial decompression/acromioplasty criteria: When requested as an arthroscopic add-on, must be performed with other medically necessary primary arthroscopic shoulder procedures (except diagnostic arthroscopy); Imaging shows BOTH plain radiographs with pathology in the subacromial space and/or AC joint AND MRI or CT findings that correlate with the individual's reported symptoms and physical exam; Physical exam demonstrates ANY listed positive impingement tests (e.g., Neer, Hawkins-Kennedy); Symptoms include function-limiting pain; Failure of provider-directed non-surgical management for at least three (3) months; Other potential pathological conditions have been excluded (e.g., fracture, thoracic outlet syndrome, brachial plexus disorders, referred neck pain, cervical radiculopathy, and advanced glenohumeral osteoarthritis).

inv-10: Labral Repair

Labral repair is considered medically necessary when ALL of the following criteria have been met:

Labral repair criteria: MRI or CT shows a labral tear (e.g., SLAP) that correlates with the individual's reported symptoms and physical exam findings; Physical exam demonstrates minimally limited or full shoulder range of motion and ANY listed positive labral tests/signs (e.g., O'Brien's, biceps load, clunk, anterior slide, compression rotation, Speed's, modified dynamic labral shear); Symptoms include function-limiting pain; Failure of provider-directed non-surgical management for at least three (3) months; Other potential pathological conditions have been excluded (e.g., fracture, thoracic outlet syndrome, brachial plexus disorders, referred neck pain, cervical radiculopathy, and advanced glenohumeral osteoarthritis).

Positive tests: O'Brien's, biceps load, clunk, anterior slide, compression rotation, Speed's, modified dynamic labral shear.

inv-11: Labral Repair — Medically Necessary

Labral repair is considered medically necessary when ALL of the following criteria have been met:

Labral repair criteria: MRI or CT shows labral tear (e.g., SLAP) and correlates with the individual's reported symptoms and physical exam findings; Physical exam demonstrates BOTH minimally limited or full shoulder ROM and ANY listed positive orthopedic tests; Symptoms include function-limiting pain; Failure of provider-directed non-surgical management for at least three (3) months; Other potential pathological conditions have been excluded.3 months

Positive tests: O'Brien's, biceps load, clunk, anterior slide, compression rotation, Speed's, modified dynamic labral shear.

inv-12: Biceps Tenodesis — Medically Necessary

Biceps tenodesis is considered medically necessary when ALL of the following criteria have been met:

Biceps tenodesis criteria: MRI or CT shows labral tear or biceps tendon pathology that correlates with the individual's reported symptoms and physical exam findings; Physical exam demonstrates minimally limited or full shoulder ROM and ANY listed positive orthopedic tests/signs (e.g., O'Brien's, biceps load, clunk, anterior slide, compression rotation, Speed's, upper cut, Yergason's, proximal biceps tenderness, modified dynamic labral shear, Popeye sign); Symptoms include function-limiting pain; Failure of provider-directed non-surgical management for at least three (3) months (exception: acute proximal biceps tendon rupture from a discrete traumatic event does not require 3-month trial); Other potential pathological conditions have been excluded (e.g., fracture, thoracic outlet syndrome, brachial plexus disorders, referred neck pain, cervical radiculopathy, and advanced glenohumeral osteoarthritis).3 months (exception applies)

Positive tests include upper cut, Yergason's, proximal biceps tenderness, Popeye sign.

inv-13: Arthroscopic/Open Procedures for Instability/Laxity — Medically Necessary

Arthroscopic or open surgical procedures for shoulder instability and/or laxity are considered medically necessary when ALL of the following criteria have been met:

Instability/laxity surgery criteria: MRI or CT shows labral, capsular, or bony pathology (e.g., Bankart, capsular tear, Hill-Sachs deformity) that correlates with the individual's reported symptoms and physical exam findings; Physical exam demonstrates ANY listed positive instability tests (e.g., anterior/posterior apprehension, sulcus sign, load and shift); Documented history of post-traumatic or atraumatic instability resulting in function-limiting pain; Failure of provider-directed non-surgical management for at least three (3) months including shoulder stabilization/strengthening exercises; Exceptions: 3-month conservative trial not required for irreducible shoulder dislocation or anterior instability in competitive contact/collision athletes; Other potential pathological conditions have been excluded (e.g., fracture, thoracic outlet syndrome, brachial plexus disorders, referred neck pain, cervical radiculopathy, and advanced glenohumeral osteoarthritis).3 months (exceptions noted)

Positive tests: anterior/posterior apprehension, sulcus sign, load and shift.

inv-14: Arthroscopic Capsular Release — Medically Necessary

Arthroscopic capsular release is considered medically necessary when ALL of the following criteria have been met:

Capsular release criteria: Performed for chronic refractory adhesive capsulitis or arthrofibrosis; Physical exam demonstrates functionally-limited and painful global loss of active and passive range of motion of at least 50% compared to the non-involved side; Symptoms include function-limiting pain for at least six (6) months; Failure of provider-directed non-surgical management for at least three (3) months, including anti-inflammatory medication, cortisone injection, and a trial of physical therapy (active exercise and manual therapy); Other potential pathological conditions have been excluded (e.g., fracture, thoracic outlet syndrome, brachial plexus disorders, referred neck pain, cervical radiculopathy, and advanced glenohumeral osteoarthritis).6 months symptoms; 3 months non-surgical trial; >=50% ROM loss

Specific non-surgical elements required: medication, injection, PT (active exercise and manual therapy).

inv-15: Experimental, Investigational, or Unproven (EIU)

Procedures considered experimental, investigational, or unproven:

EIU procedures: Superior capsular reconstruction using any type of graft (autograft, allograft, xenograft, or synthetic) is considered experimental, investigational, or unproven.

Based on lack of scientific evidence of efficacy and safety.

inv-16: Lysis of Adhesions - Medically Necessary

Lysis of adhesions is considered medically necessary when ALL of the following criteria have been met:

Lysis of adhesions criteria: Performed for chronic refractory adhesive capsulitis or arthrofibrosis; Physical exam demonstrates functionally-limited and painful global loss of active and passive range of motion of at least 50% compared to the non-involved side; Symptoms include function-limiting pain for at least six (6) months; Failure of provider-directed non-surgical management for at least three (3) months, including anti-inflammatory medication, cortisone injection, and a trial of physical therapy (active exercise and manual therapy); Other potential pathological conditions have been excluded (e.g., fracture, thoracic outlet syndrome, brachial plexus disorders, referred neck pain, cervical radiculopathy, and advanced glenohumeral osteoarthritis).see node details

All listed conditions must be satisfied before lysis of adhesions is considered medically necessary.

This coverage policy is guidance for making medical necessity and coverage determinations for Cigna plans administered by eviCore. It does not replace the terms of a member's benefit plan; a customer's benefit plan document always supersedes this coverage policy. Coverage determinations require consideration of the applicable benefit plan terms, any laws or regulations, relevant collateral materials (including coverage policies), and the specific clinical facts of the case. Coverage policies are not treatment recommendations and may not apply to all benefit plans.

Procedures listed in their respective indication sections are explicitly limited to those indications. Each of the following procedures is stated as not medically necessary for any indication or condition not explicitly listed in the policy: diagnostic arthroscopy, loose/foreign body removal, synovectomy, and debridement. In addition, the policy specifically identifies in-office diagnostic arthroscopy devices (e.g., Mi-Eye™, VisionScope®) as not medically necessary due to lack of evidence of efficacy and safety.

The policy declares several common shoulder procedures as not medically necessary when performed for any indication other than those specified in their respective indications sections. This includes debridement, rotator cuff repair, distal clavicle excision, and subacromial decompression/acromioplasty — each is limited to the clinical criteria listed in the policy and may be denied if performed for non-listed indications.

The policy applies the same exclusion principle across additional procedures: labral repair, biceps tenodesis, and procedures for shoulder instability/laxity are all not medically necessary for any indication or condition outside the explicit criteria described in their sections. Arthroscopic capsular release is similarly restricted to its listed indications and is not medically necessary for other conditions.

Arthroscopic capsular release is permitted only where the specific medically necessary criteria are met (see capsular release criteria). The policy states that arthroscopic capsular release is not medically necessary for any indication or condition other than those specified in the policy.

Lysis of adhesions is limited to the defined medically necessary indication (chronic refractory adhesive capsulitis/arthrofibrosis meeting the policy's clinical thresholds). The policy explicitly notes that lysis of adhesions is not medically necessary for any other indication or condition.

Items and procedures that the policy designates as Experimental, Investigational, or Unproven (EIU) are treated as exclusions from coverage. Requests for procedures or codes identified as EIU within the policy may be subject to denial.

The policy includes a bibliography listing the evidence sources used in developing the guidance. These reference sections provide supporting literature citations and do not introduce additional coverage exclusions or modify the stated criteria.

The policy explicitly considers "in-office" diagnostic arthroscopy devices (for example, Mi-Eye™ and VisionScope®) to be not medically necessary because of insufficient evidence of efficacy and safety; such use is therefore excluded from coverage.

Across the policy, each listed surgical procedure is restricted to the indications and criteria explicitly stated in its section. Consequently, procedures performed for indications beyond those listed are declared not medically necessary and may be denied. This overarching rule applies to the full set of procedures covered (diagnostic arthroscopy, loose/foreign body removal, synovectomy, debridement, rotator cuff repair, distal clavicle excision, subacromial decompression/acromioplasty, labral repair, biceps tenodesis, instability procedures, capsular release, and lysis of adhesions).

The policy identifies superior capsular reconstruction using any graft type (autograft, allograft, xenograft, or synthetic) as experimental, investigational, or unproven based on lack of scientific evidence of efficacy and safety; therefore it is excluded from coverage.

Labral repair is limited to the indications and clinical criteria specified in the labral repair section. The policy states that labral repair is not medically necessary for any other indication or condition.

Biceps tenodesis is covered only when the listed criteria are met; the policy explicitly states that biceps tenodesis is not medically necessary for any other indication or condition.

Arthroscopic or open procedures for shoulder instability and/or laxity are limited to the indications in the policy. The policy declares such procedures not medically necessary for any other indication or condition beyond the specified criteria.

As restated in the policy's exclusions, arthroscopic capsular release is explicitly not medically necessary for any indication or condition other than those specified in the capsular release criteria.

The policy reiterates that arthroscopic capsular release is limited to the defined indications and is not medically necessary for any other indication or condition.

The policy repeats that lysis of adhesions is restricted to the listed medically necessary indications and is not medically necessary for any other indication or condition.

Some reference chunks in the document contain bibliographic entries and do not include explicit 'not medically necessary' rulings. These reference sections serve to document the evidence base and do not change the policy's coverage statements.

Codes and Key Clinical Thresholds

Codes (CMM-315) (section exists later in document)mixed

No codes listed

Document references (no explicit CPT/ICD codes listed in this section)mixed

No codes listed

Experimental/Investigational/Unproven Codes (selected list)CPTExperimental

23000	Removal of subdeltoid calcareous deposits, open
23020	Capsular contracture release (e.g. Sever type procedure)
23106	Arthrotomy; sternoclavicular joint, with synovectomy, with or without biopsy
23120	Claviculectomy; partial
23130	Acromioplasty or acromionectomy, partial, with or without coracoacromial ligament release
23145	Excision or curettage of bone cyst or benign tumor of clavicle or scapula; with
23155	Excision or curettage of bone cyst or benign tumor of proximal humerus; with autograft (includes obtaining graft)
23172	Sequestrectomy (e.g. for osteomyelitis or bone abscess), scapula
23174	Sequestrectomy, humeral head to surgical neck
23410	Repair of ruptured musculotendinous cuff (e.g., rotator cuff) open; acute

1–10 of 35

1/4

Codes (CMM-315)CPT

29822	Arthroscopy, shoulder, surgical; diagnostic (separate procedure)
29823	Arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures (e.g., humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies])
29824	Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford procedure)
29825	Arthroscopy, shoulder, surgical; with lysis and resection of adhesions, with or without manipulation
29826	Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (i.e., arch) release when performed
29827	Arthroscopy, shoulder, surgical; with rotator cuff repair
29828	Arthroscopy, shoulder, surgical; biceps tenodesis

Non-surgical management duration — >= 3 months

Required duration>= 3 months of provider-directed non-surgical management prior to surgical authorization

Definition of non-surgical managementProvider-directed conservative care (e.g., supervised physiotherapy, medications, injections, activity modification)

DocumentationClinical documentation must demonstrate failure of non-surgical management and correlate imaging and exam findings with symptoms

Symptom duration for diagnostic arthroscopy — >= 6 months

Symptom duration>= 6 months of function‑limiting pain required for diagnostic arthroscopy

Additional requirementMRI or CT inconclusive for internal derangement/pathology

Non-surgical trial>= 3 months of provider-directed non-surgical management

Duration of non-surgical management — >= 3 months

Required duration>= 3 months of provider-directed non-surgical management prior to surgery

Exception noteException applies for discrete traumatic acute full‑thickness rotator cuff tear without pre-existing chronic tear (no 3‑month trial required)

DocumentationImaging (MRI/CT) and physical exam findings must correlate with symptoms; presence of fatty infiltration/muscle atrophy negates trauma exception

Duration of non-surgical management — >= 3 months (exceptions for certain acute traumatic injuries)

Standard requirement>= 3 months of provider-directed non-surgical management for most procedures prior to authorization

ExceptionsExceptions to the 3‑month requirement exist in certain acute traumatic injuries (e.g., irreducible dislocation, acute locking from loose/foreign body, or acute proximal biceps tendon rupture)

Required documentationClinical record must document imaging and exam findings and reason for any exception to the conservative trial

Duration of symptoms for capsular release — >= 6 months

Symptom duration>= 6 months of function‑limiting pain required before capsular release is considered medically necessary

Non-surgical trial>= 3 months including anti-inflammatory medication, cortisone injection, and physical therapy (active exercise and manual therapy)

Exclusion of other pathologyOther potential pathological conditions must be excluded (e.g., fracture, thoracic outlet syndrome, brachial plexus disorders, referred neck pain, cervical radiculopathy, advanced glenohumeral osteoarthritis)

Range of motion loss threshold for capsular release — >= 50% global loss (active and passive) vs. non-involved side

ROM loss threshold>= 50% global loss of active AND passive range of motion compared to the non-involved side

MeasurementLoss must be demonstrated on physical exam and compared to the contralateral (non‑involved) shoulder

Applies toArthroscopic capsular release and lysis of adhesions for chronic refractory adhesive capsulitis/arthrofibrosis

Range of motion loss threshold — >=50% loss of active and passive ROM compared to non-involved side

ROM loss requirement>= 50% loss of active AND passive range of motion compared to the non-involved side

Symptom duration>= 6 months of function‑limiting pain required (for lysis of adhesions) and failure of >= 3 months conservative care

Conservative care specificsConservative care must include anti‑inflammatory medication, cortisone injection, and physical therapy

CPT 29823 — referenced in document

CPT code29823 — Arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures

ContextListed in the policy Codes (CMM-315) section as an included CPT descriptor

UseInclude this CPT code with clinical documentation when applicable for authorization submissions

CPT 29826 — referenced in document

CPT code29826 — Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty

ContextListed in the policy Codes (CMM-315) section and referenced in subacromial decompression/acromioplasty criteria

RequirementWhen requested as arthroscopic add‑on, must be performed with other medically necessary primary arthroscopic shoulder procedures (except diagnostic arthroscopy)

Authorization, Documentation, and Billing Guidance

Note

Policy used for medical necessity determinations

This coverage policy is used by medical directors and other health care professionals to make medical necessity and coverage determinations for Cigna plans administered by eviCore; refer to the Codes (CMM-315) section for CPT codes that may be subject to review.

Prior Authorization

Confirm procedure-specific medical necessity with authorization

Obtain authorization that confirms the requested procedure meets the procedure‑specific medical necessity criteria, including imaging confirmation, specified physical exam findings, symptom duration, and prior non‑surgical management.

Prior Authorization

Show imaging, exam findings, and failed conservative care for PA

Prior authorization must include documentation demonstrating the listed imaging and physical exam criteria and evidence of failed provider‑directed non‑surgical management for at least three months (exceptions apply as specified in the policy).

Prior Authorization

Demonstrate all listed criteria for the surgical indication

When requesting authorization, provide evidence that all criteria for the specific surgical indication are met — imaging‑correlated pathology, specified physical exam findings, function‑limiting symptoms, and the appropriate duration of non‑surgical management or applicable exception.

Billing Rule

MUA is incidental and included in base arthroscopic procedures

Manipulation under anesthesia (MUA) of the shoulder is considered incidental to arthroscopic shoulder procedures and is included in the base procedure subject to medical necessity review; do not bill MUA separately when performed as part of the arthroscopic procedure.

Prior Authorization

Use exact CPT codes (e.g., 29822–29828) when requesting authorization

Request prior authorization using the exact CPT codes for the intended arthroscopic shoulder procedure(s); example CPT codes listed in the policy include 29822–29828.

Examples listed: 29822, 29823, 29824, 29825, 29826, 29827, 29828

Note

References section contains no PA instructions

The bibliographic/reference section contains no prior authorization instructions or affected billing codes; do not rely on the references section for PA guidance.

Documentation Required

Definition of conservative (non‑surgical) care

Non‑surgical management is defined as provider‑directed conservative care such as activity modification, supervised physiotherapy and therapeutic exercises, medications, assistive devices, and/or injections.

Includes supervised physiotherapy, medications, injections, activity modification

Step Therapy

Require ≥3 months of provider‑directed conservative care before surgery

Most surgical indications require documented failure of at least three months of provider‑directed non‑surgical management prior to authorization, with exceptions specified in the policy for certain acute mechanical presentations.

Standard prerequisite: ≥3 months of provider‑directed non‑surgical management
Exceptions noted for acute mechanical locking from a loose/foreign body and certain acute traumatic injuries

Step Therapy

Document ≥3‑month conservative therapy trial prior to surgery

Authorization for most procedures requires documentation of a trial of provider‑directed non‑surgical management for at least three months before surgical approval is considered.

Step Therapy

Trial of conservative therapies required; specific elements for capsular release

Required non‑surgical management generally includes conservative therapies for a trial typically of at least three months; for capsular release the trial must include anti‑inflammatory medication, cortisone injection, and physical therapy.

Typical duration: ≥3 months
Capsular release prerequisites: anti‑inflammatory meds, cortisone injection, and PT (active exercise and manual therapy)

Step Therapy

Conservative therapy (≥3 months) required before lysis of adhesions

For lysis of adhesions, document a trial of non‑surgical management including anti‑inflammatory medication, cortisone injection, and physical therapy for at least three months before authorization is considered.

Conservative care elements: anti‑inflammatory meds, cortisone injection, physical therapy
Required duration: ≥3 months

Note

No step therapy requirements in references section

No step therapy requirements are specified in the references section of the policy.

Documentation Required

Support decisions with case‑by‑case documentation and benefit plan review

Maintain clinical documentation to support medical necessity decisions on a case‑by‑case basis, considering the applicable benefit plan, laws/regulations, relevant coverage policies, and the specific clinical facts.

Documentation Required

Document imaging and physical exam findings compared to contralateral side

Document imaging findings (MRI or CT/arthrogram where specified) and physical exam findings compared to the non‑involved side, including symptom severity/duration and prior non‑surgical management with duration.

Include MRI or CT correlating with symptoms when required
Compare range of motion and strength to the contralateral side
Record duration of symptoms and duration of prior non‑surgical care (e.g., ≥3 months)

Documentation Required

Include plain radiographs and MRI/CT correlating with symptoms

When applicable, include plain radiographs plus MRI or CT that correlate with the individual's symptoms and physical exam findings to support medical necessity.

Plain radiographs and MRI/CT required for distal clavicle excision and subacromial decompression (exceptions noted)

Prior Authorization

Provide imaging, detailed physical exam, and prior conservative care in PA

Authorization submissions must include imaging (MRI or CT) correlating with symptoms and detailed physical exam documentation comparing findings to the non‑involved side, plus record of prior conservative care and its duration.

Documentation Required

Document ≥50% global ROM loss and conservative care failure for lysis

For lysis of adhesions, document functionally‑limited and painful global loss of active and passive range of motion of at least 50% compared to the non‑involved side, symptom duration ≥6 months, and failure of ≥3 months of conservative care.

ROM loss threshold: ≥50% global loss (active and passive) vs. non‑involved side
Symptom duration: ≥6 months
Conservative care failure: ≥3 months

Documentation Required

Document exclusion of other pathological conditions pre‑procedure

Document exclusion of other potential pathological conditions (e.g., fracture, thoracic outlet syndrome, brachial plexus disorders, referred neck pain, cervical radiculopathy, advanced glenohumeral osteoarthritis) before proceeding.

List exclusions evaluated and ruled out in the medical record

Prior Authorization

Include applicable CPT codes and clinical documentation with PA

When submitting authorization for shoulder arthroscopy procedures, include the applicable CPT codes (examples listed 29822–29828) and the clinical documentation supporting medical necessity.

Include exact CPT code(s) and supporting imaging/exam documentation with PA

Note

References section does not specify documentation requirements

These bibliographic/reference chunks do not specify clinical documentation requirements.

Denial Risk

Benefit plan document supersedes policy for coverage decisions

When coverage determinations conflict with a customer's benefit plan, the benefit plan document supersedes this coverage policy; consider the benefit plan terms first when making authorization or denial decisions.

Denial Risk

Risk of denial if procedure indication is not one of the listed criteria

Procedures performed for indications other than those listed in the policy (e.g., diagnostic arthroscopy, loose body removal, synovectomy, debridement for non‑listed conditions) are considered not medically necessary and may be denied.

Denial Risk

Denial risk when procedure is for non‑specified conditions

Requests for procedures performed for indications outside the specified criteria (e.g., debridement, rotator cuff repair, distal clavicle excision, subacromial decompression for other conditions) are considered not medically necessary and may be denied.

Denial Risk

Not medically necessary triggers for procedures outside listed indications

Procedures conducted for indications not explicitly listed (including labral repair, biceps tenodesis, instability surgery, arthroscopic capsular release outside the stated criteria) are considered not medically necessary and may trigger denial.

Denial Risk

Arthroscopic capsular release is NMN outside listed indications

Arthroscopic capsular release is considered not medically necessary for any indication or condition other than those specifically listed in the policy.

Denial Risk

Lysis of adhesions is NMN outside listed indications

Lysis of adhesions is considered not medically necessary for any indication or condition other than those specifically listed in the policy.

Denial Risk

Coracoplasty/subcoracoid decompression classified as EIU

Arthroscopic or open coracoplasty/subcoracoid decompression for subcoracoid impingement is considered experimental, investigational, or unproven; requests for this procedure may be denied as EIU.

Denial Risk

EIU-designated procedures/codes may be denied

Requests for procedures or codes identified as Experimental, Investigational, or Unproven (EIU) within the policy may be subject to denial.

Note

References section contains no authorization/denial criteria

The bibliographic/reference chunks do not contain authorization or denial criteria and should not be used as the basis for PA decisions.

Background and Scope

This policy provides clinical definitions and classifications for common shoulder conditions to support application of the coverage criteria. Definitions include adhesive capsulitis/arthrofibrosis (stiffness, loss of motion, scarring around the shoulder), rotator cuff tear (partial- and full-thickness tears with Ellman and Cofield classifications), rotator cuff arthropathy, and other condition descriptors used throughout the policy. These definitions assist reviewers in interpreting imaging, physical exam findings, symptom duration, and prior non-surgical management when determining medical necessity.

Key Definitions and Clinical Classifications

Adhesive Capsulitis / Arthrofibrosis — definition

DefinitionA condition of the shoulder characterized by stiffness, loss of motion (contracture), and pain due to scarring in and/or around the shoulder joint (also called frozen shoulder)

ClassificationPrimary (idiopathic) and secondary (following trauma, surgery, or other causes) forms described

Associated factorsConditions that may predispose: trauma, shoulder surgery, inflammatory diseases, diabetes, hyperthyroidism, dyslipidemia

Rotator Cuff Tear (RCT) — partial/full‑thickness classifications (Ellman, Cofield)

Partial‑thickness classification (Ellman)Grade 1: <3 mm (<25% thickness); Grade 2: 3–6 mm (≤50% thickness); Grade 3: >6 mm (>50% thickness)

Full‑thickness classification (Cofield)Small <1 cm; Medium 1–3 cm; Large 3–5 cm; Massive >5 cm

RelevanceEllman grades 2–3 (partial) and Cofield full‑thickness tears are cited as criteria for rotator cuff repair

Non-Surgical Management — definition of conservative care

DefinitionProvider-directed non-surgical treatments considered efficacious or reasonable, including activity modification, supervised physiotherapy/exercises, medications, assistive devices, and injections

PurposeRequired as a trial (typically >=3 months) before many surgical interventions unless exceptions apply

ExamplesSupervised physiotherapy, therapeutic exercises, prescription and nonprescription medications, injections

Distal Clavicle Excision / Acromioplasty / Subacromial Decompression — procedural definition

DefinitionProcedures involving removal of the distal clavicle at the AC joint (distal clavicle excision) and removal of bone or partial resection of the acromion/coracoacromial ligament (acromioplasty/subacromial decompression) to enlarge the subacromial space

Indication linkDistal clavicle excision and subacromial decompression criteria reference plain radiographs and MRI/CT correlating with symptoms

CodingPartial acromioplasty is CPT 29826 when performed arthroscopically

Rotator Cuff Arthropathy — definition

DefinitionA condition resulting from rotator cuff dysfunction (e.g., irreparable massive tear), advanced glenohumeral arthritis, and radiographically diminished acromio-humeral distance

Clinical relevanceAssociated with irreparable massive rotator cuff tears and may affect surgical decision-making

ImagingRadiographic evidence of diminished acromio-humeral distance supports diagnosis

Function-limiting pain — definition

DefinitionFunction‑limiting pain: loss of shoulder function that interferes with age‑appropriate activities of daily living and/or demands of employment

ApplicationUsed as a required symptom threshold across multiple procedure criteria in the policy

DocumentationMust be demonstrated in clinical notes and correlated with exam and imaging findings

Mechanical symptoms — definition

DefinitionMechanical symptoms: painful locking, clicking, catching, or popping associated with a loose or foreign body

ContextPresence of mechanical symptoms plus imaging confirmation is required for loose/foreign body removal

ExceptionAcute restriction/locking due to a loose body may obviate the 3‑month conservative trial

Rotator cuff tear classifications — Ellman grade 2-3 and Cofield full-thickness referenced

Ellman grades referencedPartial‑thickness tears of Grade 2 or 3 (Ellman) qualify as imaging criteria

Cofield full‑thicknessFull‑thickness tears (Cofield classification) qualify as imaging criteria for repair

Clinical linkageImaging classification must correlate with physical exam findings and failed conservative care

Experimental procedure — superior capsular reconstruction considered experimental/investigational/unproven

Policy stanceSuperior capsular reconstruction using any graft type (autograft, allograft, xenograft, or synthetic) is considered experimental, investigational, or unproven

ReasonDetermined based on lack of scientific evidence of efficacy and safety

Coverage implicationProcedures designated EIU are treated as exclusions from coverage and may be denied

Positive orthopedic tests for labral pathology — list of tests

Labral pathology testsO'Brien's test; biceps load test; clunk test; anterior slide test; compression rotation test; Speed's test; modified dynamic labral shear

UseAny listed positive test supports correlation of labral pathology with symptoms for labral repair authorization

DocumentationPhysical exam must demonstrate minimally limited or full ROM plus ANY listed positive tests

Positive orthopedic tests for biceps/labral pathology — list of tests

Biceps/labral testsO'Brien's test; biceps load test; clunk test; anterior slide test; compression rotation test; Speed's test; upper cut test; Yergason's test; proximal biceps groove tenderness; modified dynamic labral shear; Popeye sign

ContextPresence of ANY listed positive test supports biceps tenodesis or labral pathology criteria

ExceptionAcute proximal biceps tendon rupture may bypass the 3‑month conservative trial

Positive orthopedic tests for instability/laxity — list of tests

Instability/laxity testsAnterior apprehension test; posterior apprehension test; sulcus sign; load and shift test

ApplicationAny listed positive test plus imaging demonstrating labral/capsular/bone pathology is required for instability/laxity surgery

ExceptionsAcute irreducible dislocation or anterior instability in competitive contact/collision athletes may waive 3‑month trial

Chronic refractory adhesive capsulitis or arthrofibrosis — criteria (>=6 months symptoms and >=50% ROM loss)

Diagnostic criteriaChronic refractory adhesive capsulitis or arthrofibrosis defined by persistent (>= 6 months) function‑limiting pain AND >= 50% global loss of active and passive ROM compared to non‑involved side

Conservative care requirement>= 3 months of non‑surgical management including anti‑inflammatory meds, cortisone injection, and physical therapy

ExclusionOther potential pathological conditions must be excluded prior to lysis or capsular release

CPT 29823 — referenced CPT in definitions section

CPT code29823 — Arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures

PlacementReferenced in the Definitions / Codes section of the policy as an included CPT descriptor

Clinical useUse with appropriate documentation when debridement extensive criteria are met

CPT 29826 — referenced CPT in definitions section

CPT code29826 — Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty

PlacementReferenced in the Definitions / Codes section of the policy and described in subacromial decompression criteria

Coding noteWhen performed arthroscopically as an add‑on, should be listed in addition to the primary procedure code where applicable

Policy Revision History

2026-08-04policy_effective_dateLatest

Policy CMM-315 (Shoulder Surgery Arthroscopic and Open Procedures) effective date published as v1.0.2026.