Surgery of the Shoulder (for New Mexico Only)
UnitedHealthcare New Mexico medical policy describing coverage rationale and coding guidance for shoulder surgery procedures, references to InterQual criteria for medical necessity, and an explicit noncoverage position for subacromial balloon spacers (SABS) for rotator cuff tears as not medically necessary.
Revised language pertaining to medical necessity clinical coverage criteria to add and remove specific InterQual references.
Updated clinical evidence and references sections to reflect current information.
Coverage Summary
This UnitedHealthcare New Mexico coverage policy (Policy Number CS109NM.C) summarizes the scope and rationale for shoulder surgery coverage, relies on InterQual procedure‑specific criteria to determine medical necessity for listed shoulder procedures, and takes an explicit mixed coverage stance: conventional shoulder surgeries are covered when InterQual criteria are met, while subacromial balloon spacers (SABS) for rotator cuff tears are considered not medically necessary due to insufficient evidence. The policy includes a review of clinical evidence (systematic reviews, randomized trials, evolving evidence reviews) and notes relevant device/regulatory context including the FDA De Novo classification for the InSpace spacer.