ModifiedPremera BluecrossPolicy N/A

Shoulder Open Procedures

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Defines medical necessity criteria, documentation requirements, and coding guidance for open shoulder arthrotomy procedures in adults for specific indications such as AC separation, subacromial decompression/acromioplasty, full-thickness rotator cuff repair, distal clavicle resection, shoulder dislocation, and synovectomy.

Policy Summary

PayerPremera Bluecross

PolicyShoulder Open Procedures

Policy CodePolicy N/A

Change TypeCriteria revisedCPT list updated

Effective DateSep 4, 2026

Next Review DateN/A

Key ActionObtain and submit prior authorization with medical records documenting required conservative therapy (medication trial and 6-week PT/home exercise) and any additional testing per indication.

SourceLink

POLICY UPDATE CHANGES

Policy statements modified conservative management to require where noted for each indication both a medication trial and failure as well as a trial and failure of physical measures for specified indications.

Policy statements modified to require additional testing for specified indications (decompression/acromioplasty, full thickness rotator cuff repair, resection of distal clavicle, and shoulder dislocation).

CPT code set was updated: several codes were removed and invalid code 23770 replaced with 23680; policy CPT list updated for effective date Sept 4, 2026.

Criteria for multiple indications (AC separation with recent trauma, partial thickness rotator cuff repair, removal of intra-articular osteochondral lesion or loose body, recurrent shoulder dislocation > two years, initial shoulder dislocation with certain fractures, shoulder fracture repair, hardware removal) were deleted.

Policy title changed from 'Shoulder Arthrotomy in Adults' to 'Shoulder Open Procedures in Adults' and later to 'Shoulder Open Procedures'.

6+distinct indication-specific criteria

3 monthsfailed conservative management duration

6 weeksPT / home exercise trial

Sep 4, 2026policy effective

Medical Necessity Criteria for Shoulder Open Procedures

Acromioclavicular (AC) separation (CPT 23550, 23552)

Shoulder arthrotomy for acromioclavicular (AC) separation may be considered medically necessary when ALL of the following are met:

AC separation all-criteria: 1) One or more of the following is present: recent traumatic event; shoulder pain; or deformity. 2) Rockwood type III or higher injury diagnosed by imaging.Rockwood >= III

Imaging gold standard is x-ray; MRI may be used for soft tissue assessment or if x-ray is inconclusive; ultrasound is not typically used for grading AC separation.

Decompression of subacromial space / acromioplasty (CPT 23130)

Shoulder arthrotomy for decompression of subacromial space or acromioplasty may be considered medically necessary when ALL of the following are met:

Decompression all-criteria: 1) History of disabling shoulder pain with loss of shoulder function which interferes with activities of daily living (ADLs). 2) At least one positive orthopedic impingement test on physical exam compared to the non-affected shoulder (e.g., Hawkins-Kennedy or Neer). 3) Documentation of three months of failed non-operative conservative management including trials of NSAIDs or acetaminophen and subacromial corticosteroid injection as appropriate. 4) Trial of PT and/or directed home exercise for at least 6 weeks. 5) Plain x-rays or imaging (MRI or CT) demonstrate findings consistent with subacromial impingement (e.g., Type II or III acromion).3 months failed conservative care; 6 weeks PT

Additional diagnostic testing must be completed and documented where required per policy history.

Full thickness rotator cuff repair (CPT 23410, 23412, 23420)

Shoulder arthrotomy for full-thickness rotator cuff repair may be considered medically necessary when ALL of the following are met:

Rotator cuff repair all-criteria: 1) History of disabling shoulder or upper arm pain with loss of shoulder function which interferes with ADLs. 2) Shoulder pain or weakness on resisted abduction or rotation, and tenderness over the rotator cuff. 3) One of the following positive orthopedic tests is present: Drop arm test; Painful arc test; Empty can (Jobe) test; or Weakness of external rotation (lag/dropping sign). 4) Imaging demonstrates a partial or full-thickness rotator cuff tear (may include associated muscle atrophy, fatty replacement, or tendon retraction if chronic). 5) Documentation of three months of failed non-operative conservative management (trial of NSAIDs or acetaminophen and subacromial corticosteroid injection as appropriate) and a trial of PT and/or directed home exercise for at least 6 weeks. Exception: an acute traumatic complete tear with debilitating pain and loss of function does not require prior conservative management.

Resection of distal clavicle (CPT 23120)

Shoulder arthrotomy for resection of distal clavicle for AC joint arthritis may be considered medically necessary when ALL of the following are met:

Distal clavicle resection all-criteria: 1) History of disabling shoulder pain with loss of shoulder function which interferes with ADLs. 2) Localized tenderness to palpation of the AC joint. 3) At least one positive orthopedic test on physical exam compared to the non-affected shoulder (e.g., Cross-Body/Scarf Test or Resisted AC joint extension). 4) Documentation of three months of failed non-operative conservative management including trials of NSAIDs or acetaminophen and AC joint corticosteroid injection as appropriate, and a trial of PT and/or directed home exercise for at least 6 weeks. 5) Plain x-rays or imaging (MRI/CT) demonstrate findings consistent with AC joint arthritis.

Shoulder dislocation / capsulorrhaphy (multiple CPTs)

Shoulder arthrotomy with or without capsulorrhaphy for initial shoulder dislocation may be considered medically necessary when ALL of the following are met:

Dislocation all-criteria: 1) History of shoulder dislocation or subluxation with disabling shoulder pain and loss of shoulder function which interferes with ADLs. 2) Instability on physical examination demonstrated by any of: anterior or posterior apprehension test; load and shift test; or sulcus sign. 3) MRI demonstrating at least one of: labral lesion consistent with instability (e.g., Bankart), Hill-Sachs lesion, capsular tear (thickening/edema), or capsular redundancy consistent with multidirectional instability. 4) Documentation of three months of failed non-operative conservative management (trial of NSAIDs or acetaminophen and/or intra-articular corticosteroid injection as appropriate) and a trial of PT and/or directed home exercise for at least 6 weeks.

Synovectomy (major or complete) (CPT 23105, 23106)

Shoulder arthrotomy for synovectomy (major or complete) may be considered medically necessary when EITHER of the following conditions is present:

Synovectomy eligibility: Either: 1) Irreducible shoulder dislocation; OR 2) Anterior shoulder instability in competitive contact or collision athletes. Additionally, for synovectomy the patient should have one or more of the following symptoms: joint pain; locking; pain with range of motion; limited range of motion; crepitus; or joint effusion, and a confirmed diagnosis of an underlying synovial disorder (e.g., inflammatory arthritis such as rheumatoid arthritis or gout, hemochromatosis, hemophilia, Lyme synovitis, nonspecific/proliferative synovitis, pigmented villonodular synovitis (PVNS), recurrent hemarthrosis, or synovial chondromatosis).

Confirmed diagnosis must be documented by imaging or biopsy where appropriate.

Synovectomy (open arthrotomy) criteria

Synovectomy (open arthrotomy) is covered when ALL of the following are met:

Synovectomy medical necessity: 1) One or more listed symptoms is present: joint pain; locking; pain with range of motion; limited range of motion; crepitus; or joint effusion/swelling. 2) Imaging or biopsy demonstrates underlying pathology consistent with the reported condition (e.g., synovitis, joint effusion). 3) Documentation of three months of failed non-operative conservative management (trial of NSAIDs or acetaminophen and intra-articular corticosteroid injection as appropriate). 4) Trial of PT and/or directed home exercise for at least 6 weeks. 5) Diagnosis of one of the specified synovial conditions is present (inflammatory arthritis, hemochromatosis, hemophilia, Lyme synovitis, nonspecific synovitis, PVNS, recurrent hemarthrosis, or synovial chondromatosis).

Indications for open shoulder procedures

Open shoulder procedures (arthrotomy, open stabilization, open rotator cuff repair) are considered medically necessary when ANY of the following high-risk or structural conditions are present:

Indications for open procedures: - Recurrent anterior instability with critical glenoid bone loss or engaging/off-track Hill-Sachs lesions. - Failed prior arthroscopic stabilization. - Multidirectional instability unresponsive to conservative care. - Intra-articular loose bodies or unexplained joint pathology requiring direct visualization. - Large, massive, L-shaped, or complex rotator cuff tears (e.g., complete subscapularis tears, poor tissue quality, extensive lamination) where an open approach is preferred. - High-demand patients (contact/overhead athletes, military personnel, manual laborers) at high risk for recurrence.

Medically necessary / covered indications

Covered when ALL of the following are met (generalized from document statements):

General coverage: 1) The proposed procedure is an open shoulder procedure (arthrotomy) for an indicated diagnosis in an adult and meets the specific indication criteria detailed elsewhere in this policy (e.g., large/massive rotator cuff tear, recurrent instability with bone loss, failed prior arthroscopic repair, intra-articular loose bodies requiring open access).

Conservative management required where noted: 2) For specified indications (decompression/acromioplasty for rotator cuff tendonitis, full-thickness rotator cuff repair, resection of distal clavicle, shoulder dislocation, and synovectomy) there is documentation of both a medication trial and failure and a trial and failure of physical measures prior to surgery (typically three months of non-operative management overall with at least 6 weeks of PT/directed home exercise), unless an acute traumatic complete tear exception applies.

Additional testing required where noted: 3) For decompression/acromioplasty, full-thickness rotator cuff repair, resection of distal clavicle, and shoulder dislocation: required additional diagnostic testing (imaging and/or biopsy where specified) has been completed and documented as indicated by the policy.

Indication-specific evidence: 4) The indication is supported by relevant evidence or clinical rationale favoring an open approach (e.g., large/complex rotator cuff tears, complete subscapularis tears, failed arthroscopic repairs, significant bone loss, engaging/off-track Hill-Sachs lesions, or high-demand athletes/revision stabilization), as described in the clinical evidence sections.

All indications not listed in this policy or other clinical situations not specifically described above are considered Not Medically Necessary when policy criteria are not met. Providers should expect claims for open shoulder procedures that lack documentation meeting the applicable indication-specific criteria, required conservative management, or diagnostic testing to be evaluated as non-covered.

Open arthrotomy is reserved for select nonemergent cases when anatomical complexity, failed prior surgery, or surgeon judgment indicate an open approach is required. Arthrotomy is not the preferred first-line approach for routine shoulder conditions in which arthroscopic techniques provide sufficient exposure and therapeutic benefit; when arthroscopy is sufficient, arthrotomy should be discouraged as first-line treatment.

Policy history shows removal of several previously-stated indication criteria. Deleted indications include: AC separation with recent traumatic event (with shoulder pain and deformity); partial-thickness rotator cuff repair; removal of intra-articular osteochondral lesion or loose body; recurrent shoulder dislocation (greater than two years); certain initial or recurrent dislocations associated with Bankart, Hill-Sachs, or anterior glenoid rim fractures; shoulder fracture repair; and shoulder hardware removal.

Procedures and clinical scenarios not explicitly listed as covered indications in this policy, or those that do not meet the specific criteria described for listed indications, are designated Not Medically Necessary at the procedure level. Claims for these procedures will be reviewed against the policy criteria and supporting documentation.

The document does not include a single, explicit NMN sentence for every deleted or removed indication; where explicit Not Medically Necessary wording is absent in the main text, providers should rely on the full policy content and the deletions recorded in policy history to determine coverage—deleted indications are no longer supported under this policy and should be treated as Not Medically Necessary unless otherwise covered by another policy or benefit provision.

CPT Codes and Coding Guidance

AC separation CPT codesCPT

23550	Acromioclavicular (AC) separation repair
23552	Acromioclavicular (AC) separation repair (alternate)

Subacromial decompression/acromioplastyCPT

23130

Decompression of subacromial space or acromioplasty for rotator cuff tendonitis

Full thickness rotator cuff repair CPT codesCPT

23410	Full thickness rotator cuff repair
23412	Full thickness rotator cuff repair (alternate)
23420	Full thickness rotator cuff repair (alternate)

Resection of distal clavicle CPT codeCPT

23120

Resection of distal clavicle

Shoulder dislocation / capsulorrhaphy related CPT codesCPT

23450	Shoulder dislocation procedures
23455	Shoulder dislocation procedures
23460	Shoulder dislocation procedures
23462	Shoulder dislocation procedures
23465	Shoulder dislocation procedures
23466	Shoulder dislocation procedures
23660	Shoulder dislocation procedures
23670	Shoulder dislocation procedures
23680	Shoulder dislocation procedures

Synovectomy CPT codesCPT

23105	Synovectomy (major)
23106	Synovectomy (complete)

Covered CPT Codes (arthrotomy/synovectomy/related)CPTCovered

23105	Arthrotomy; glenohumeral joint, with synovectomy, with or without biopsy (glenohumeral synovectomy).
23106	Arthrotomy; sternoclavicular joint, with synovectomy, with or without biopsy (sternoclavicular synovectomy).
23120	Claviculectomy, partial (partial clavicle resection).
23130	Acromioplasty or acromionectomy, partial, with or without coracoacromial ligament release.

Covered CPT Codes (open repairs, stabilization, unlisted)CPTCovered

23410	Repair of ruptured musculotendinous cuff (e.g., rotator cuff) open, acute.
23412	Repair of ruptured musculotendinous cuff (e.g., rotator cuff) open chronic.
23420	Reconstruction of complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasty).
23450	Capsulorrhaphy, anterior; Putti-Platt procedure or Magnuson type operation.
23455	Capsulorrhaphy, anterior; with labral repair (e.g., Bankart procedure).
23460	Capsulorrhaphy, anterior, any type; with bone block.
23462	Capsulorrhaphy, anterior, any type; with coracoid process transfer.
23465	Capsulorrhaphy, glenohumeral joint, posterior, with or without bone block.
23466	Capsulorrhaphy, glenohumeral joint, any type multi-directional instability.
23550	Open treatment of acromioclavicular dislocation, acute or chronic.

1–10 of 15

1/2

Policy CPT Codes (listed for use when policy effective)CPT

20670
20680
23040
23044
23101
23105
23106
23107
23120
23130

1–10 of 30

1/3

Conservative management duration — key values

Required durationThree months of documented failed non-operative conservative management (NSAIDs/acetaminophen and, when appropriate, corticosteroid injection), except for acute traumatic complete tears which may be exempt

Evidence to submitMedical records documenting medication trials and failures, imaging findings, and clinical history supporting failure of conservative care

Applies toDecompression/acromioplasty, full-thickness rotator cuff repair, distal clavicle resection, shoulder dislocation procedures (when policy criteria note conservative care is required)

Physical therapy / home exercise trial duration — key values

Minimum PT/home exercise trialAt least 6 weeks of PT and/or directed home exercise documented

Concurrent treatmentsShould be part of a broader conservative program including NSAIDs/acetaminophen and appropriate corticosteroid injections as indicated

DocumentationRecords must indicate supervised PT or a directed home exercise program with dates, frequency, and response to therapy

Prior Authorization, Documentation, and Billing Requirements

Prior Authorization

Prior Authorization Required

Prior Authorization Required: Prior authorization is required (implied) for services billed with the CPT codes listed in this policy. Medical records and supporting documentation must be submitted with the request to demonstrate that medical necessity criteria are met.

Effective date for policy CPT list: 2026-09-04
Submit complete medical records with prior authorization request (history, exam, imaging, prior therapies, test results)

Billing Rule

CPT Codes Affected by This Policy

The following CPT codes are affected by this policy and require adherence to the policy criteria and prior authorization when billed: use these codes for dates of service on or after 2026-09-04.

23105 Arthrotomy; glenohumeral joint, with synovectomy, with or without biopsy
23106 Arthrotomy; sternoclavicular joint, with synovectomy, with or without biopsy
23120 Claviculectomy, partial (partial clavicle resection)
23130 Acromioplasty or acromionectomy, partial, with or without coracoacromial ligament release
23410 Repair of ruptured musculotendinous cuff, open, acute
23412 Repair of ruptured musculotendinous cuff, open, chronic
23420 Reconstruction of complete shoulder cuff avulsion, chronic (includes acromioplasty)
23450 Capsulorrhaphy, anterior; Putti-Platt or Magnuson type
23455 Capsulorrhaphy, anterior; with labral repair (e.g., Bankart)
23460 Capsulorrhaphy, anterior, any type; with bone block
23462 Capsulorrhaphy, anterior; with coracoid process transfer
23465 Capsulorrhaphy, glenohumeral joint, posterior, with or without bone block
23466 Capsulorrhaphy, glenohumeral joint, any type multi-directional instability
23550 Open treatment of acromioclavicular dislocation, acute or chronic
23552 Open treatment of acromioclavicular dislocation; with fascial graft
23660 Open treatment of acute shoulder dislocation (open reduction)
23670 Open treatment of shoulder dislocation, with fracture of greater humeral tuberosity, includes internal fixation
23680 Open treatment of shoulder dislocation, with surgical or anatomical neck fracture, includes internal fixation
23939 Unlisted procedure, shoulder

Note

Not Listed Indications

Indications not explicitly listed in the policy are considered not medically necessary. Procedures performed for conditions or situations not described by the policy criteria (or without meeting the stated criteria) may be denied.

All indications not listed or situations not described in the policy are considered not medically necessary
If policy criteria are not met, the service is not covered

Step Therapy

Conservative Therapy Prerequisites

Conservative management must be documented per the specific indication. For certain indications the policy requires both a medication trial and a trial of physical measures; failure of both must be documented prior to authorization for open procedures.

Medications: trial of one or more of NSAIDs, acetaminophen, and where indicated corticosteroid injection (subacromial or intra-articular)
Physical measures: PT and/or directed home exercise for at least 6 weeks
When noted for an indication (e.g., acromioplasty, full thickness rotator cuff repair, distal clavicle resection, shoulder dislocation, synovectomy) documentation must show trials and failures of both medications and physical measures (typically 3 months total for medications and >=6 weeks for PT)

Denial Risk

Documentation Insufficient for Conservative Management Trial — Denial Risk

Insufficient documentation of the required conservative management (for example, no documentation of a 3-month medication trial or absence of a PT/home exercise trial of at least 6 weeks) places the claim at high risk for denial. Ensure dates, therapies tried, response to therapy, and reasons for failure are clearly documented.

Failure to document a 3-month trial of conservative medication where required may result in denial
Failure to document PT/directed home exercise for at least 6 weeks where required may result in denial
If additional testing required per indication (e.g., imaging demonstrating rotator cuff tear, Rockwood classification for AC separation, MRI evidence for labral lesion or Hill-Sachs), absence of these tests may lead to denial

Documentation Required

Documentation Requirements (General)

Documentation requirements: submit complete medical records to support medical necessity. Records should include history, physical exam with applicable positive orthopedic tests, imaging reports, details of conservative therapies attempted (medications, injections, PT/home exercise), dates and duration of trials, and results of any specified testing.

History and physical exam notes with documentation of symptoms and functional impairment (ADLs)
Positive orthopedic test(s) relevant to the indication (e.g., Hawkins-Kennedy, Neer, Drop arm, Jobe, apprehension, load and shift)
Imaging reports: x-ray, MRI, or CT as specified for the indication (e.g., Rockwood classification, evidence of rotator cuff tear, labral lesion, Hill-Sachs)
Detailed record of conservative management: medications tried (names, doses, dates, response), corticosteroid injections (site and date), PT or home exercise (duration and adherence)
Operative reports or consultation notes when applicable

Background and Rationale

Shoulder arthrotomy is an open surgical incision into the glenohumeral joint used to diagnose or treat intra-articular pathology when less invasive approaches are insufficient. It provides direct visualization and access for procedures such as debridement, drainage, synovectomy, large or complex rotator cuff repair, and stabilization with bone transfer (e.g., Latarjet) when there are significant bony defects or failed prior arthroscopic repairs. Open approaches are particularly indicated in complex anatomy, large/massive tears, significant glenoid bone loss, failed prior stabilization, and some high-risk or revision cases; these procedures generally have longer recoveries and often require postoperative physical therapy.

Definitions and Surgical Terminology

Shoulder arthrotomy — definition

DefinitionAn open surgical incision into the glenohumeral joint to directly visualize and treat intra-articular pathology when less invasive methods (imaging or arthroscopy) are insufficient

Common usesDebridement, drainage, synovectomy, repair of large or complex tears, treatment of infection or refractory joint disease

Recovery considerationsLonger recovery than arthroscopy; often requires postoperative physical therapy

Synovectomy — definition

DefinitionOpen surgical excision of inflamed synovial tissue from the glenohumeral joint, performed for chronic synovitis or other synovial diseases unresponsive to conservative care

IndicationsInflammatory arthritis (eg, rheumatoid), PVNS, recurrent hemarthrosis, synovial chondromatosis, or biopsy-confirmed synovitis with symptoms such as pain, locking, limited ROM, crepitus, or effusion

DocumentationRequires imaging or biopsy demonstrating underlying pathology and documentation of failed conservative management (3 months) plus PT/home exercise trial (≥6 weeks)

Acromioplasty — definition

DefinitionRemoval (partial) of the acromion to increase the subacromial space and relieve pressure on the rotator cuff, used to treat subacromial impingement

Diagnostic criteriaHistory of disabling shoulder pain, at least one positive impingement test (Hawkins-Kennedy or Neer), imaging consistent with Type II or III acromion

Conservative care before surgeryDocumentation of three months failed conservative management and PT/home exercise trial of at least 6 weeks required for coverage

Rotator cuff tear classifications (Cofield, Ellman)

Cofield classification (tear size)Small <1 cm; Medium 1–3 cm; Large 3–5 cm; Massive >5 cm

Ellman classification (partial-thickness depth)Grade 1 <3 mm; Grade 2 = 3–6 mm; Grade 3 >6 mm

UseClassifications guide surgical approach and help determine when open repair is preferred for large or complex tears

Open rotator cuff repair — situations where open repair is preferred

Preferred clinical situationsLarge or massive tears (eg, L-shaped or >3–5 cm), complete subscapularis tears, poor tissue quality or extensive lamination, and previously failed arthroscopic repairs — open repair is preferred

RationaleOpen repair provides improved access and precision for complex or revision repairs where arthroscopy may be insufficient

EvidenceSystematic reviews and cohort studies support open repair advantages in selected large/complex tears (Mohammed et al., Zarezadeh)

Latarjet / open stabilization — indications

IndicationsRecurrent anterior instability with critical glenoid bone loss or engaging/off-track Hill-Sachs lesions; significant glenoid bone loss; High-demand athletes or revision cases (eg, failed prior arthroscopic stabilization) where Latarjet or other open stabilization provides greater durability

Patient groupsYoung contact/overhead athletes, military personnel, and manual laborers at high risk of recurrence—open stabilization (Latarjet) often preferred

Evidence and outcomesRCTs and cohort studies show open procedures (including Latarjet) maintain lower recurrence and higher return-to-sport in selected high-risk populations

Policy Changes and Effective Dates

2026-09-04policy_update_effective_dateLatest

Policy effective date updated to September 4, 2026, with revised CPT code list and required 90-day provider notification.

2026-06-01interim_review

Interim review approved May 12, 2026: removed multiple CPT codes (including invalid code 23770 replaced by 23680), made minor formatting corrections, and changed policy title to 'Shoulder Open Procedures in Adults'.

2025-12-01new_policy_approval

New policy approved November 11, 2025 and published December 1, 2025; effective March 4, 2026 with an initial CPT code list to apply when effective.

2025-12-01criteria_revision

Policy statements modified to require both medication trial/failure and a trial/failure of physical measures for specified indications and to require additional testing for several indications; multiple prior indication criteria were deleted.

Title and deletion history: The policy title was edited in history from 'Shoulder Arthrotomy in Adults' to 'Shoulder Open Procedures in Adults' and later to 'Shoulder Open Procedures' to better reflect scope. Multiple prior indication criteria were removed in interim updates; see history for a list of deleted indications including AC separation with recent trauma, partial-thickness rotator cuff repair, removal of intra-articular osteochondral lesion or loose body, certain recurrent or fracture-associated dislocation indications, shoulder fracture repair, and hardware removal.

Policy Summary

PayerPremera Bluecross

PolicyShoulder Open Procedures

Policy CodePolicy N/A

Change TypeCriteria revisedCPT list updated

Effective DateSep 4, 2026

Next Review DateN/A

SourceLink

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