CurrentPremera BluecrossPolicy 7.01.602

Shoulder Arthroscopy in Adults

Defines medical necessity, site-of-service determinations, specific indications (rotator cuff repair, SLAP repair, capsular release/adhesive capsulitis, capsulorrhaphy for instability/laxity, distal clavicular excision, loose/foreign body removal, subacromial decompression, synovectomy), documentation requirements, and CPT coding for arthroscopic shoulder procedures for adult members.

Policy Summary

PayerPremera Bluecross

PolicyShoulder Arthroscopy in Adults

Policy CodePolicy 7.01.602

Change TypeMaterial updates to coverage criteria and site-of-service rules

Effective DateApr 1, 2026

Next Review Date

Key ActionSubmit medical records documenting that the applicable medical necessity criteria are met (history, exam findings, imaging, documentation of conservative management and PT durations, and diagnosis-specific findings).

SourceLink

POLICY UPDATE CHANGES

New policy approved October 14, 2025; effective for dates of service on or after February 6, 2026 following 90-day provider notification.

Interim review (approved March 10, 2026) modified conservative management requirement to require both medication trial and failure and a trial and failure of physical measures where noted for each indication.

Minor update correction on 04/09/26 to remove header hyperlinks and separate subacromial decomposition/acromioplasty inadvertently missed.

Minor update on 06/01/26 added header that site of service review does not apply to Indian Health Services (IHS) facilities.

9Named covered indications

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Coverage Summary

Overview: This policy defines medical necessity for arthroscopic shoulder procedures in adults and lists named covered indications (rotator cuff repair, SLAP repair, capsular release/adhesive capsulitis, capsulorrhaphy for instability/laxity, distal clavicular excision/Mumford procedure, loose/foreign body removal, subacromial decompression/acromioplasty, synovectomy). It includes site-of-service guidance favoring Ambulatory Surgical Centers (ASC) with criteria for when hospital outpatient or inpatient settings are medically necessary, and identifies documentation and conservative management requirements (medication trial and failure plus trial and failure of physical measures where noted).

Effective/Review Dates: Effective: Apr. 1, 2026; Last review: Jun. 1, 2026.

Quick thresholds

Conservative management duration (most indications)3 months of failed non-operative conservative management

Physical therapy duration (typical)At least 6 weeks of PT (may include PT-directed home exercise)

Physical therapy duration (capsular release)At least 12 weeks of PT

Capsular release refractory periodDocumentation of 6 months of failed non-operative conservative management

Anesthesia/procedure risk thresholdProlonged surgery defined as greater than 3 hours

Liver risk threshold (MELD)MELD score greater than 8

Pulmonary risk (FEV1)COPD: FEV1 < 50%; Poorly controlled asthma: FEV1 < 80% despite treatment

Morbid obesity threshold (BMI)BMI greater than or equal to 50

Medical-Necessity Criteria (by indication)

Rotator cuff repair (CPT 29827)

ALL of the following

Rotator cuff repair (CPT 29827) - required criteria
- Clinical history: History of disabling shoulder or upper arm pain with loss of shoulder function which interferes with activities of daily living (ADLs)
- Exam finding: Shoulder pain or weakness on resisted abduction or rotation
- Orthopedic test (one required): One of the following positive orthopedic tests is present: Drop arm test; Painful arc test; Empty can test (aka Jobe test); Weakness of external rotation (lag/dropping sign)

Not Medically Necessary / Exclusions

Thermal capsulorrhaphy

Thermal capsulorrhaphy - policy stance: Thermal capsulorrhaphy (e.g., ORA-50, ArthroCare, Vulcan, VAPR II) as treatment of joint instability of the shoulder is considered not medically necessary

Rationale: lack of efficacy in comparative studies, high rate of unsatisfactory results and complications; potential for net harm

All other indications or situations

All other indications or situations - policy stance: Shoulder arthroscopy for indications not listed above or when the above criteria are not met is considered not medically necessary

Rationale: Thermal capsulorrhaphy is considered not medically necessary because the literature does not support its efficacy and available studies report high rates of unsatisfactory results and complications, creating potential for net harm. Additionally, the policy states that shoulder arthroscopy for indications not listed in the policy or when criteria are not met is considered not medically necessary.

CPT Coding

Covered CPT codes (arthroscopic shoulder procedures referenced in policy)CPTCovered

29806	Arthroscopy, shoulder, surgical; capsulorrhaphy
29807	Arthroscopy, shoulder, surgical; repair of SLAP lesion
29819	Arthroscopy, shoulder, surgical; with removal of loose body or foreign body
29820	Arthroscopy, shoulder, surgical; synovectomy, partial
29821	Arthroscopy, shoulder, surgical; synovectomy, complete
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
29827	Arthroscopy, shoulder, surgical; with rotator cuff repair
23929	Unlisted procedure, shoulder

1–10 of 11

1/2

Removed CPT codes (per history)CPT

29805	Arthroscopy, shoulder, diagnostic
29822	Arthroscopy, shoulder, debridement
29823	Arthroscopy, shoulder, with removal of foreign body, loose body
29828	Arthroscopy, shoulder, synovectomy

Provider Actions and Operational Requirements

Prior Authorization

Medical necessity review and site-of-service review required

Shoulder arthroscopy is an elective surgical procedure that will be reviewed for medical necessity; the site-of-service for the procedure will also be reviewed to determine ASC versus hospital outpatient or inpatient settings based on the policy's site-of-service criteria and patient risk factors.

ASC is the preferred medically necessary site for certain elective surgical procedures (see site-of-service criteria in policy).
On-campus or off-campus hospital outpatient settings may be considered when no qualifying ASC is available, patient is ≤18 years old, or procedures are performed with an additional service requiring hospital outpatient department.
Individuals with increased perioperative risk factors (e.g., ASA III+, significant cardiac, pulmonary, liver, renal risks, morbid obesity, bleeding disorders) may require hospital-based care.

Documentation Required

Support medical necessity with records

Background and Evidence Summary

Background and clinical rationale: Shoulder arthroscopy is a minimally invasive method to diagnose and treat intra‑articular and periarticular shoulder pathology (e.g., rotator cuff tears, instability, synovitis) when conservative care fails. Preferred site-of-service is an Ambulatory Surgical Center (ASC) for appropriate elective procedures, with hospital outpatient or inpatient care considered when ASC access is unavailable or the individual has increased perioperative risk. Examples of risk factors necessitating hospital‑based care include ASA class III or higher, recent MI or stroke, uncompensated heart failure, advanced liver disease (MELD >8), COPD with FEV1 <50%, poorly controlled asthma with FEV1 <80%, ESRD on dialysis, morbid obesity (BMI ≥50), bleeding disorders requiring replacement products, or anticipated transfusion.

Rotator cuff repair coverage considerations (evidence summary)

Evidence summary points informing rotator cuff repair coverage considerations.

Rotator cuff evidence summary: Surgical repair may be medically necessary for symptomatic full-thickness rotator cuff tears not responding to conservative care; conservative management reasonable for isolated, symptomatic, nontraumatic supraspinatus tears. RCTs and systematic reviews show little or no benefit of surgery up to one year for some populations; long-term (10-15 year) data (Moosmayer 2024) may favor repair for small-to-medium tears.

Labral (SLAP) tear considerations

Definitions

Term	Definition
Conservative management	Trial of medications (NSAIDs or acetaminophen), and as appropriate corticosteroid injections; specific durations apply (typically 3 months) unless exceptions noted.
ASA classification III	American Society of Anesthesiologists physical status classification indicating severe systemic disease (see Definitions section).
Thermal capsulorrhaphy	Use of thermal energy to shrink collagen in the shoulder capsule to tighten capsule and ligaments (devices include ORA-50, ArthroCare, Vulcan, VAPR II); considered not medically necessary as treatment for shoulder instability.
SLAP tear	Superior labral anterior posterior tear involving the labrum where the biceps tendon attaches.

Medicare Determinations

Name/Type	Number	Detail	Effective
Medicare National Coverage (NCD)		There is no national coverage determination.	none

Revision History

October 14, 2025policy_added

New policy approved October 14, 2025; effective for dates of service on or after February 6, 2026 following 90-day provider notification. Added to Surgical section; shoulder arthroscopy in adults considered medically necessary for indicated criteria; Site of Service ASC Select Surgical Procedures criteria added; Thermal capsulorrhaphy considered not medically necessary.

03/10/2026policy_revised

Interim review approved March 10, 2026: modified conservative management requirement to require both medication trial and failure and a trial and failure of physical measures where noted for each indication; removed criteria for diagnostic arthroscopy, debridement arthroscopy, and biceps tenodesis; removed specific tenderness criterion under rotator cuff; separated distal clavicular excision and subacromial decompression/acromioplasty criteria; removed CPT codes 29805, 29822, 29823, 29828.

Policy Summary

PayerPremera Bluecross

PolicyShoulder Arthroscopy in Adults

Policy CodePolicy 7.01.602

Change TypeMaterial updates to coverage criteria and site-of-service rules

Effective DateApr 1, 2026

Next Review Date

SourceLink

On This Page

SLAP tear repair (CPT 29807)

SLAP tear repair (CPT 29807) - required criteria

Clinical history: History of disabling shoulder pain and loss of shoulder function which interferes with activities of daily living (ADLs)
Range of motion: Normal or minimally limited active or passive shoulder ROM worsened by heavy lifting, pushing, or overhead movement compared to unaffected shoulder
Orthopedic test (one required): One of the following positive orthopedic tests is present: Active Compression Test (O'Brien's); Anterior Slide Test; Crank Test (Passive Compression/Labral Crank Test)
Imaging demonstrates a SLAP tear
Medication trial: Documentation of three months of failed non-operative conservative management: NSAIDs or acetaminophen; intra-articular corticosteroid injection as appropriate3 months
Physical measures: Trial of physical measures: PT for at least 6 weeks (may include PT-directed home exercise)6 weeks

evidence_note: See evidence considerations re: SLAP repair outcomes and age-related differences

Capsular release/adhesive capsulitis (CPT 29825)

Capsular release/adhesive capsulitis (CPT 29825) - required criteria

Clinical history: History of disabling shoulder pain and loss of shoulder function which interferes with activities of daily living (ADLs)
Diagnosis: History of chronic refractory adhesive capsulitis or arthrofibrosis resulting from disease, injury, or surgery
Range of motion: Limited active and passive shoulder range of motion
Conservative management duration: Documentation of six months of failed non-operative conservative management: NSAIDs or acetaminophen; intra-articular corticosteroid injection as appropriate6 months
Physical measures: Trial of physical measures: PT for at least 12 weeks (may include PT-directed home exercise)12 weeks

evidence_note: RCTs and meta-analyses compare ACR, MUA, and PT+steroid; none clinically superior at 12 months although ACR may improve ROM

Capsulorrhaphy for instability and/or laxity (CPT 29806)

Capsulorrhaphy for instability/laxity (CPT 29806) - required criteria

Clinical history: History of shoulder dislocation or subluxation with disabling shoulder pain and loss of shoulder function which interferes with ADLs
Physical exam instability (one required): Instability found on physical exam demonstrated by any of the following positive tests/signs: Anterior or posterior apprehension test; Load and shift test; Sulcus sign
Imaging findings (one required): MRI findings demonstrate at least ONE of the following: labral lesion consistent with clinical instability (e.g., Bankart), Hill-Sachs lesion, capsular tear (thickening and edema), capsular redundancy with clinical multidirectional instability
Medication trial: Documentation of three months of failed non-operative conservative management: NSAIDs or acetaminophen; intra-articular corticosteroid injection as appropriate3 months
Physical measures: Trial of physical measures: PT for at least 6 weeks (may include PT-directed home exercise)6 weeks

exceptions_note: Conservative management not required in acute traumatic injury when irreducible shoulder dislocation, or anterior shoulder instability in competitive contact/collision athletes

Distal clavicular excision / Mumford procedure (CPT 29824)

Distal clavicular excision / Mumford procedure (CPT 29824) - required criteria

Clinical history: History of disabling shoulder pain with loss of shoulder function which interferes with ADLs
Tenderness: Localized tenderness to palpation of the acromioclavicular (AC) joint
Orthopedic test (one required): At least ONE positive orthopedic test on physical exam compared to non-affected shoulder: Cross-Body Adduction Test (Scarf), Resisted AC Joint Extension Test
Medication trial: Documentation of three months of failed non-operative conservative management: NSAIDs or acetaminophen; subacromial corticosteroid injection as appropriate3 months
Physical measures: Trial of physical measures: PT for at least 6 weeks (may include PT-directed home exercise)6 weeks
Imaging: Plain x-rays or imaging (MRI or CT) demonstrate findings consistent with AC joint arthritis

documentation_reference: See Documentation Requirements for required supporting records

Loose or foreign body removal (CPT 29819)

Loose or foreign body removal (CPT 29819) - required criteria

Imaging: MRI or CT demonstrates a loose body or foreign body within the shoulder joint
Symptoms include BOTH: disabling shoulder pain and loss of shoulder function interfering with ADLs; AND mechanical symptoms including painful locking, clicking, catching, or popping
Medication trial: Documentation of three months of failed non-operative conservative management: NSAIDs or acetaminophen; intra-articular corticosteroid injection as appropriate3 months
Physical measures: Trial of physical measures: PT for at least 6 weeks (may include PT-directed home exercise)6 weeks

documentation_reference: See Documentation Requirements for imaging and conservative management documentation

Subacromial decompression/acromioplasty (CPT 29826)

May be considered add-on only with other medically necessary primary shoulder surgical procedures.

Subacromial decompression/acromioplasty (CPT 29826) - required criteria

Clinical history: History of disabling shoulder pain with loss of shoulder function which interferes with ADLs
Orthopedic test (one required): At least ONE positive orthopedic test on physical exam compared to non-affected shoulder: Hawkins-Kennedy Impingement Test; Neer Impingement Test
Medication trial: Documentation of three months of failed non-operative conservative management: NSAIDs or acetaminophen; subacromial corticosteroid injection as appropriate3 months
Physical measures: Trial of physical measures: PT for at least 6 weeks (may include PT-directed home exercise)6 weeks
Imaging: Plain x-rays or imaging (MRI or CT) demonstrate findings consistent with subacromial impingement (e.g., Type II or III acromions)

evidence_note: High-certainty evidence shows no clinically important benefit of subacromial decompression over placebo or exercise; policy separates criteria for clarity

Synovectomy (partial or complete) (CPT 29820, 29821)

Synovectomy (partial or complete) (CPT 29820, 29821) - required criteria

Symptoms (one or more): One or more of the following symptoms is present: joint pain; locking; pain with ROM; limited ROM; crepitus; joint effusion or swelling
Pathology confirmation: Imaging or biopsy demonstrates underlying pathology consistent with the reported medical condition (e.g., synovitis, joint effusion)
Medication trial: Documentation of three months of failed non-operative conservative management: NSAIDs or acetaminophen; intra-articular corticosteroid injection as appropriate3 months
Physical measures: Trial of physical measures: PT for at least 6 weeks (may include PT-directed home exercise)6 weeks
Eligible diagnoses (one required): Diagnosis of ONE of the following conditions is present: Inflammatory arthritis (rheumatoid arthritis, gout, psoriatic arthritis, pseudogout); Hemochromatosis; Hemophilia; Lyme synovitis; Non-specific synovitis (proliferative, post-operative); Pigmented villonodular synovitis (PVNS); Recurrent hemarthrosis secondary to sickle cell anemia or bleeding diathesis; Synovial chondromatosis

documentation_reference: See Documentation Requirements for diagnostic confirmation and conservative management documentation

Site of Service for Elective Surgical Procedures

Site-of-service decision tree for elective surgical procedures; IHS exclusion noted.

Medically necessary sites: One of the following sites is medically necessary when criteria met: Ambulatory surgical center (preferred medically necessary site for certain elective surgical procedures); Off campus-outpatient hospital/medical center; On campus-outpatient hospital/medical center (considered medically necessary if no access to ASC within 30 miles due to lack of equipment, lack of physician privileges at ASC, ASC guideline prohibits use related to individual's health condition or weight; OR individual is aged 18 or younger; OR service performed with additional service requiring hospital outpatient in same operative session)

Site of service review does not apply to Indian Health Services (IHS) facilities

Not medically necessary sites (when site criteria not met): On campus-outpatient hospital/medical center when site criteria above are not met; Inpatient hospital/medical center for this elective surgical procedure

Examples of increased risk conditions (one or more): Individuals with a clinical condition placing them at increased risk for complications including one or more of the following: Anesthesia risk (ASA III or higher; personal history of complication of anesthesia; documentation of alcohol dependence or history of cocaine use; prolonged surgery > 3 hours); Cardiovascular risk (uncompensated chronic heart failure NYHA III or IV; MI within 3 months; poorly controlled/resistant hypertension defined as 3 or more drugs; recent cerebrovascular accident <3 months; increased risk for cardiac ischemia [DES <1 year or angioplasty <90 days]; symptomatic cardiac arrhythmia despite medication; significant valvular heart disease); Liver risk (advanced liver disease MELD > 8); Pulmonary risk (COPD with FEV1 < 50%; poorly controlled asthma with FEV1 < 80% despite treatment; moderate to severe OSA); Renal risk (end stage renal disease on dialysis); Other (morbid obesity BMI >= 50; bleeding disorder requiring replacement factor/blood products/special infusion product [DDAVP does not meet]; anticipated need for transfusion(s))

These examples are used to determine if hospital-based site is necessary

General coverage statement

General operational coverage statement and operational notes.

General coverage statement: Shoulder arthroscopy in adults is considered medically necessary for the indications noted when criteria are met.

Conservative management operational change: Conservative management where noted requires BOTH a medication trial and failure and a trial and failure of physical measures (per interim review effective 04/01/26)

Site-of-service IHS exception: Site of Service review (ASC criteria) does not apply to Indian Health Services (IHS) facilities (added 06/01/26)

Indication correspondence: Indication corresponds to one of the surgical indications detailed in the policy (e.g., rotator cuff repair, labral tear repair when criteria met, biceps tenotomy/tenodesis as appropriate, arthroscopic capsular release or manipulation for adhesive capsulitis when criteria met, subacromial decompression when criteria met)

History of disabling shoulder or upper arm pain with loss of shoulder function interfering with ADLs (as applicable by indication).
Relevant physical exam findings and one or more positive orthopedic tests per indication (examples: Drop arm, Painful arc, Empty can, Active Compression/O'Brien, Hawkins-Kennedy, Neer, Sulcus sign, apprehension/load-and-shift).
Imaging demonstrating the diagnosis (e.g., MRI/CT or x-ray findings consistent with the indicated pathology).
Documentation of conservative management: medication trials (NSAIDs or acetaminophen; corticosteroid injections as appropriate) and durations where specified.
Documentation of physical measures: PT durations per indication (commonly ≥6 weeks; capsular release 12 weeks; see policy thresholds).

Documentation Required

Conservative management documentation required

For indications requiring conservative management, providers must document trials and failures of both medication therapy and physical measures per the interim review effective 04/01/26.

Dual requirement: trial and failure of medication therapy (e.g., NSAIDs or acetaminophen; injections as appropriate) AND trial and failure of physical measures (physical therapy or PT-directed home exercise).
Interim review change effective 04/01/26 modified conservative management to require both medication trial/failure and trial/failure of physical measures where noted for each indication.

Denial Risk

Potential denial if criteria not met

Claims may be denied if indication-specific criteria, required imaging findings, or documentation of conservative management and PT durations are not provided to demonstrate that medical necessity criteria are met.

Indication-specific positive exam findings and imaging (e.g., MRI showing rotator cuff tear or SLAP tear) must be documented.
Required conservative management and PT trial durations must be documented unless exception applies (e.g., acute traumatic complete tear or other noted exceptions).
Thermal capsulorrhaphy is specifically listed as not medically necessary and claims for it are at risk for denial.

Billing Rule

Site of service review and ASC criteria

Include ASC Select Surgical Procedures criteria when determining site of service; site-of-service review does not apply to Indian Health Services (IHS) facilities.

Preferred site: Ambulatory Surgical Center for certain elective procedures when criteria met.
Hospital outpatient (on- or off-campus) or inpatient settings may be appropriate when ASC access is unavailable or patient meets listed risk exceptions.
Site of service review does not apply to Indian Health Services (IHS) facilities (06/01/26 update).

Subacromial decompression

Evidence summary and policy implication for subacromial decompression.

Subacromial decompression evidence: High-certainty evidence from placebo-controlled trials and systematic reviews does not support clinical benefit of subacromial decompression over placebo surgery or exercise for subacromial impingement/rotator cuff disease; policy separated out subacromial decompression/acromioplasty criteria for clarity (04/01/26).

Evidence highlights (key trials/reviews):

- Beard et al. (CSAW RCT): no clinically important benefit of subacromial decompression over arthroscopy alone or no treatment at one year.

- Schrøder et al. (2017 SLAP trial): no significant benefit of labral repair or biceps tenodesis over sham surgery at 24 months for Type II SLAP lesions.

- Rangan et al. (2020, UK FROST RCT): no clinically superior intervention at 12 months among manipulation under anesthesia (MUA), arthroscopic capsular release (ACR), and early structured physical therapy plus steroid.

- Moosmayer long‑term follow-up (2024): at 15 years primary tendon repair was superior to physiotherapy for small‑to‑medium rotator cuff tears on multiple shoulder function outcomes.