ModifiedUnitedHealthcarePolicy CS109ID.B

Surgery of the Shoulder (for Idaho Only)

Defines medical necessity and coverage stance for shoulder surgical procedures for UnitedHealthcare members in Idaho, including Idaho Medicaid Plus; includes stance on subacromial balloon spacers.

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Shoulder (for Idaho Only)

Policy CodePolicy CS109ID.B

Change TypeRevised clinical criteria and documentation language

Effective DateFeb 1, 2026

Next Review Date

Key ActionReference InterQual Procedures criteria when requesting prior authorization for shoulder surgical procedures and include complete medical record documentation to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

Revised language pertaining to medical necessity clinical coverage criteria and added/removed references to InterQual modules and documentation requirements.

Updated Clinical Evidence and References sections to reflect most current information.

Idaho-onlyState-specific application

InterQual referencedClinical criteria source

Not medically necessarySABS coverage stance

FDA DeNovo (2021)InSpace regulatory

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Coverage Criteria for Shoulder Procedures

Surgical procedures (general)

Covered when ALL of the following are met per InterQual procedural criteria

InterQual-based surgical coverage: Shoulder surgical procedures are covered when medical necessity is met according to the InterQual CP: Procedures criteria (including arthroscopy, arthrotomy, joint replacement, removal/replacement or revision of shoulder joint replacement).per InterQual

Provider must apply the specific InterQual criteria relevant to the requested procedure.

Subacromial Balloon Spacers (SABS)

Device-specific coverage determination

SABS not medically necessary: Subacromial balloon spacers for the treatment of rotator cuff tears (including InSpace) are considered unproven and not medically necessary due to insufficient and low-quality evidence regarding efficacy and long-term outcomes.evidence insufficient

Multiple systematic reviews, evolving evidence reviews, and RCTs show limited, inconsistent, or short-term benefit and highlight heterogeneity and bias in available studies.

Evidence, guidance, and regulatory context

Evidence summary and external guidance relevant to coverage decisions

Evidence reviews: Hayes evolving evidence reviews and ECRI assessments report limited to low-quality evidence; small studies and short follow-up limit conclusions about comparative effectiveness and long-term benefit.

See Hayes (2022, 2023, 2025) and ECRI (2021, updated 2024) summaries for details.

NICE guidance: NICE (IPG 775, 2023) recommends: do not use biodegradable subacromial spacer when debridement is a suitable option; use spacer only in research when debridement is not suitable; further RCTs with at least 2 years follow-up and multidisciplinary patient selection are needed.follow-up >= 2 years

Selection and procedure should be performed by appropriately trained multidisciplinary teams.

FDA device indication: The InSpace Subacromial Tissue Spacer System received FDA DeNovo (2021) Class II classification with an indication for individuals >=65 years with massive, irreparable full-thickness rotator cuff tears and mild to moderate glenohumeral osteoarthritis when a shorter surgical time compared to partial rotator cuff repair is desired; regulatory status is informational only and not a coverage determination.

UnitedHealthcare excludes the use of subacromial balloon spacers (SABS) for the treatment of rotator cuff tears. The policy position is that these devices are not medically necessary due to insufficient evidence of efficacy and durability.

The National Institute for Health and Care Excellence (NICE, IPG 775, 2023) explicitly advises that when debridement is a suitable option, biodegradable subacromial spacer insertion for rotator cuff tears should not be used. NICE further recommends that if debridement is not suitable, spacer insertion be limited to research settings with randomized trials and at least 2 years of follow-up.

Subacromial balloon spacers, including the InSpace system, are considered unproven for treating rotator cuff tears and are therefore not medically necessary. The literature is limited by short-term follow-up, small and nonrandomized studies, heterogeneity of designs, and potential industry-related bias, which prevents definitive conclusions about benefit.

Current evidence regarding SABS is low quality and inconclusive. Systematic reviews, evolving evidence reviews, and assessments (Hayes, ECRI) report small studies, methodological limitations, and a lack of long-term outcomes — with no consistent demonstration of comparative effectiveness versus debridement or partial repair. These limitations mean potential clinical benefit should be interpreted cautiously and further high-quality trials with longer follow-up are needed.

Procedure and Related Codes

Applicable procedure CPT codesCPT

23470	Arthroplasty, glenohumeral joint; hemiarthroplasty.
23472	Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (e.g., total shoulder)).
23473	Revision of total shoulder arthroplasty, including allograft when performed; humeral or glenoid component.
23474	Revision of total shoulder arthroplasty, including allograft when performed; humeral and glenoid component.
29805	Arthroscopy, shoulder, diagnostic, with or without synovial biopsy (separate procedure).
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.

1–10 of 18

1/2

Verma RCT enrollment criteria (example threshold)

Imaging criteriaMRI showing a full-thickness massive rotator cuff tear ≥5 cm and involving ≥2 tendons

AgeAge ≥40 years at enrollment

Conservative therapyFailed conservative therapy for at least 4 months prior to enrollment

Functional statusFunctional deltoid muscle and preserved passive range of motion on physical exam

Symptom severityVisual Analog Scale (VAS) score >30 mm

Provider Requirements and Actions

Prior Authorization

Prior authorization and InterQual criteria

Prior authorization and medical necessity determinations reference InterQual® Procedures criteria. Clinical coverage for shoulder surgical procedures follows the InterQual CP: Procedures pathways (for example: Arthroscopy or Arthroscopically Assisted Surgery, Shoulder; Arthroscopy, Diagnostic, +/- Synovial Biopsy, Shoulder; Arthrotomy, Shoulder; Joint Replacement, Shoulder; Removal and Replacement or Revision, Joint Replacement, Shoulder). Verify whether prior authorization is required per the member's plan and follow InterQual criteria when submitting requests.

InterQual® CP: Procedures — shoulder procedure pathways

Note

Verify benefit and provide documentation

Benefit coverage is determined by the federal, state, or contractual requirements that govern the member's plan. Verify member benefits and eligibility prior to scheduling or performing services. Medical records and other documentation may be required to determine if the member meets clinical criteria; providing documentation does not guarantee coverage.

Verify plan benefits and any federal/state/contractual mandates prior to authorization or claim submission

Clinical Background

Massive, irreparable rotator cuff tears (MIRCTs) may be managed with a range of surgical options including debridement, partial rotator cuff repair, tendon transfers, superior capsular reconstruction, reverse total shoulder arthroplasty, and investigational approaches such as biodegradable subacromial balloon spacers. The policy notes that spacers are investigational given the limitations of the evidence base.

Device and Clinical Definitions

InSpace biodegradable subacromial spacer

Device nameInSpace Subacromial Tissue Spacer System (Stryker)

DescriptionMinimally invasive, biodegradable balloon spacer placed in the subacromial space to reduce friction between the acromion and humeral head

Intended useUsed to restore shoulder function and reduce pain for massive, inoperable rotator cuff tears (MIRCTs)

BiodegradationDesigned to biodegrade over approximately 12 months

ManufacturerStryker (InSpace™ Subacromial Tissue Spacer System manufactured by Ortho-Space Ltd., distributed by Stryker)

MIRCT — Definition of Massive, irreparable rotator cuff tears

Policy Revision History

2026-02-01policy_revisionLatest

Revised medical necessity clinical coverage criteria language: added reference to InterQual CP: Procedures, Removal and Replacement or Revision, Joint Replacement, Shoulder; removed older InterQual references; expanded medical records documentation language clarifying federal/state/contractual determination and required documentation details.