CurrentIndependent HealthPolicy M20210611027

Shoulder Joint Replacements

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Medical necessity criteria and prior authorization requirements for shoulder joint replacement procedures (including total, hemi, and reverse shoulder arthroplasty) for Independent Health members across Commercial, Medicare Advantage, MediSource, Child Health Plus, and Essential Plan lines of business.

Policy Summary

PayerIndependent Health

PolicyShoulder Joint Replacements

Policy CodePolicy M20210611027

Change TypeNo material clinical or coverage changes

Effective DateSep 1, 2021

Last ReviewAug 1, 2025

Next Review DateN/A

Key ActionObtain preauthorization with documentation of approximately 3 months of conservative management and a clinical assessment within 3 months of the request.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6+symptom duration (months)

2+radiographic findings

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CurrentIndependent HealthPolicy M20210611027

Shoulder Joint Replacements

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Policy Summary

PayerIndependent Health

PolicyShoulder Joint Replacements

Policy CodePolicy M20210611027

Change TypeNo material clinical or coverage changes

Effective DateSep 1, 2021

Last ReviewAug 1, 2025

Next Review DateN/A

Key ActionObtain preauthorization with documentation of approximately 3 months of conservative management and a clinical assessment within 3 months of the request.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6+symptom duration (months)

2+radiographic findings

conservative therapy (months)

HbA1c>8.5%glycemic threshold

Medically Necessary and Not Medically Necessary Criteria

Medically necessary criteria

Covered when ALL of the following are met:

Overall

Procedure indication
- Malignancy involving the glenohumeral joint or surrounding soft tissue
- Proximal humerus fracture not amenable to internal fixation
- Advanced joint disease of the shoulder meeting the advanced-disease requirements below
- Aseptic loosening of one or more prosthetic components confirmed by imaging (for revision procedures)
- Revision or replacement of a shoulder prosthesis with one or more of: fracture of component(s) confirmed by imaging; instability of glenoid or humeral components; periprosthetic infection confirmed by stain and culture; migration of the humeral head
Advanced-disease requirements
- One or more of: osteoarthritis; rheumatoid arthritis; avascular necrosis; post-traumatic arthritis; osteonecrosis of the humeral head without glenoid involvement; rotator cuff tear arthropathy
- Pain and loss of function of at least 6 months' duration that interferes with daily activities
- Limited range of motion or crepitus of the glenohumeral joint on physical examination
- Radiographic evidence of destructive degenerative joint disease with 2 or more of: glenoid sclerosis; irregular joint surfaces; osteophyte changes; cystic changes in the humeral head; flattened glenoid; joint space narrowing
Conservative management
- Two or more of: activity modification (with description and outcomes); physical therapy (complete therapy progress notes); prescription or OTC anti-inflammatory medications/analgesics (name, dose, frequency, start/end dates, outcomes); physician- or PT-supervised therapeutic home exercise program (progress notes); intra-articular corticosteroid injection(s) (procedure report and outcomes)
Preoperative suitability and documentation
- Anticipated level of function should place limited demands on the shoulder joint
- Deltoid muscle is intact
- Shoulder joint is anatomically and structurally suited to receive implants (adequate bone stock to allow firm fixation)
- Specific functional limitations related to symptoms, symptom duration and severity documented
- Type and duration of all therapeutic measures provided, or clear documentation why conservative management is not appropriate
- Documented clinical assessment by the requesting provider within 3 months of the request

The following clinical conditions are explicitly listed as not covered for shoulder joint replacement procedures: active infection of the joint, active systemic bacteremia, and rapidly progressive neurologic disease. Also excluded are active skin infection at the planned surgical site (with the stated exception of recurrent cutaneous Staphylococcus infections) or an open wound within the planned surgical site, and glenohumeral osteoarthritis with an irreparable rotator cuff tear.

Total shoulder arthroplasty or hemiarthroplasty is not covered when performed in clinical situations that would place excessive stress on the implant. Examples explicitly cited include arthropathy conditions such as a Charcot joint and paralytic conditions of the shoulder. Procedures undertaken under these circumstances are considered not medically necessary and may be denied.

Key Thresholds and Required Durations

inv-04: Duration of conservative therapy — 3 months

Duration of conservative therapyDocumentation of a reasonable attempt at conservative therapy for approximately 3 months (medical records showing non‑surgical management measures for a period of 3 months)

Required elementsConservative therapy must include at least two nonoperative strategies with start and end dates and outcomes (e.g., activity modification, physical therapy, medications, home exercise program, intra‑articular corticosteroid injection)

Documentation neededTherapy progress notes, procedure reports for injections, and medication records (name, dose, frequency, start/end dates) must be submitted

inv-05: Required duration of symptoms — Pain and loss of function of at least 6 months' duration

Required duration of symptomsPain and loss of function of at least 6 months' duration that interferes with daily activities

Prior Authorization, Documentation, and Exclusions

Prior Authorization

Prior Authorization Required

Preauthorization is required for shoulder joint replacement. Requests must include documentation of prior conservative management and supporting clinical evidence as detailed below.

Preauthorization required for shoulder joint replacement (including reverse shoulder arthroplasty).
Request must include documentation of conservative management and supporting clinical evidence.

Documentation Required

Conservative Therapy Prerequisites

A reasonable trial of conservative (nonoperative) therapy is required prior to authorization unless documentation explains why it is not appropriate. The medical record must document a combination of strategies to reduce inflammation, alleviate pain, and improve function, including at least two of the therapies listed below, with start and end dates and treatment outcomes.

At least two nonoperative strategies from the list below: activity modification; physical therapy with complete progress notes; prescription or OTC anti-inflammatory/analgesic medication with name, dose, frequency, start/end dates and outcomes; physician- or PT-supervised therapeutic home exercise program with progress notes; intraarticular corticosteroid injection with procedure report and outcomes.

Clinical Background

Shoulder arthroplasty (total, hemi, or reverse) is indicated when nonoperative measures fail to control pain or dysfunction attributable to joint destruction. Typical indications include advanced glenohumeral joint disease such as avascular necrosis, post‑traumatic arthritis, rotator cuff tear arthropathy, and other causes of intractable joint pain or unacceptable functional decline. Coverage requires documentation that symptoms (pain and loss of function) have persisted for at least 6 months, that exam and imaging demonstrate limited range of motion or crepitus with radiographic evidence of destructive degenerative joint disease (at least 2 radiographic findings), and that a reasonable trial of conservative management (approximately 3 months and including at least two nonoperative strategies) was attempted without adequate improvement. Definitions: a hemiarthroplasty replaces the humeral head with a metal ball and stem, and a reverse shoulder arthroplasty reverses the ball-and-socket orientation to allow the deltoid to elevate the arm when the rotator cuff is deficient.

Procedure Definitions

inv-13: Hemiarthroplasty — replacement of the humeral head with a metal ball and stem.

DefinitionHemiarthroplasty is a surgical procedure where the head of the humerus is replaced with a metal ball and stem.

Typical indicationUsed when replacement of the humeral head is required but a glenoid component is not placed (e.g., certain fractures, selected joint disease)

Component descriptionInvolves implantation of a metal ball attached to a stem inserted into the humerus

inv-14: Reverse shoulder arthroplasty — attachment of a metal ball to the shoulder bone and a plastic socket to the upper arm bone.

DefinitionReverse shoulder arthroplasty is a surgical procedure where a metal ball is attached to the shoulder (glenoid) bone and a plastic socket is attached to the upper arm (humeral) bone to allow the deltoid to lift the arm instead of a torn rotator cuff.

Policy Summary

PayerIndependent Health

PolicyShoulder Joint Replacements

Policy CodePolicy M20210611027

Change TypeNo material clinical or coverage changes

Effective DateSep 1, 2021

Last ReviewAug 1, 2025

Next Review DateN/A

Key ActionObtain preauthorization with documentation of approximately 3 months of conservative management and a clinical assessment within 3 months of the request.

SourceLink

On This Page

Associated exam findingsLimited range of motion or crepitus of the glenohumeral joint on physical examination must be documented

Functional impactSpecific functional limitations related to symptoms should be described in the medical record

inv-06: Glycemic control threshold — HbA1c > 8.5%

Glycemic control thresholdFor members with diabetes, poor control is defined as HbA1c > 8.5%; efforts should be made to optimize glycemic levels prior to elective surgery

If optimization not possibleIf optimization was not possible, documentation that the surgeon reviewed the increased risks associated with joint replacement with the member is required

Perioperative considerationGlycemic control must be addressed in medical record as part of preoperative risk assessment

inv-07: Radiographic evidence threshold — 2 or more radiographic signs of destructive degenerative joint disease

Radiographic evidence thresholdRadiographic evidence of destructive degenerative joint disease demonstrated by 2 or more findings

Examples of radiographic findingsGlenoid sclerosis; irregular joint surfaces; osteophyte changes; cystic changes in the humeral head; flattened glenoid; joint space narrowing

Imaging requirementRadiographic findings must be documented to support advanced joint disease in the medical record

Documentation of the start and end dates for each therapy and the results/outcomes of therapy.

A documented plan of therapy and compliance for a minimum conservative management period of approximately 3 months unless clinically inappropriate.

Smoking status: either documented abstinence from tobacco for at least 6 weeks prior to surgery or documentation that benefits of cessation were reviewed if the member continues to smoke.

For members with significant comorbidities (e.g., CAD, COPD) documentation that risks/benefits were addressed; for diabetes, efforts to optimize glycemic control or documentation that risks were discussed if optimization was not possible.

Denial Risk

Not Covered Clinical Conditions

Shoulder joint replacement (including total, hemiarthroplasty, and reverse shoulder arthroplasty) is NOT COVERED when any of the following clinical conditions are present. Such conditions should be clearly documented in the medical record and will result in a denial of coverage for the procedure.

Active infection of the joint.
Active systemic bacteremia.
Active skin infection or open wound at the planned surgical site (exception: recurrent cutaneous Staphylococcus infections as specified by clinical judgment).
Glenohumeral osteoarthritis with an irreparable rotator cuff tear.
Conditions that would place excessive stress on the implant (e.g., Charcot joint, paralytic conditions of the shoulder).
Rapidly progressive neurologic disease.
Glenoid bone loss precluding implant fixation or instability of glenoid/humeral components that cannot be addressed surgically.

Functional rationale

Design reverses normal anatomy so the deltoid muscle compensates for deficient rotator cuff function

Component descriptionImplant includes a metal glenosphere and a humeral cup (plastic) affixed to the humerus

inv-15: Shoulder joint replacement (arthroplasty) — replacement of arthritic joint surfaces with a polished metal ball on a stem and a plastic socket.

DefinitionShoulder joint replacement (arthroplasty) is a surgical procedure where the arthritic joint surfaces are replaced with a highly polished metal ball attached to a stem and a plastic socket.

PurposeReplaces worn joint surfaces to relieve pain and restore function in advanced shoulder joint disease

ComponentsTypically involves a polished metal humeral head on a stem and a polyethylene glenoid component (plastic socket)