CurrentUnitedHealthcarePolicy CS109TN.W

Surgery of the Shoulder (for Tennessee Only)

UnitedHealthcare medical policy for shoulder surgery applicable to Tennessee Medicaid and CoverKids. Defines that shoulder surgeries are medically necessary per referenced InterQual CP procedures and states subacromial balloon spacers (SABS) are unproven and not medically necessary for rotator cuff tears.

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Shoulder (for Tennessee Only)

Policy CodePolicy CS109TN.W

Change TypeRevisedUpdated evidence

Effective DateNov 1, 2025

Next Review Date

Key ActionProviders must refer to and document that the procedure meets the applicable InterQual CP: Procedures criteria to support medical necessity for covered shoulder surgeries.

SourceLink

POLICY UPDATE CHANGES

Revised language pertaining to medical necessity clinical coverage criteria, added reference to InterQual CP: Procedures Removal and Replacement or Revision, Joint Replacement, Shoulder and removed reference to certain InterQual shoulder procedure entries.

Updated Clinical Evidence and References sections to reflect current information.

1State-specific policy (Tennessee only)

SABS: excludedCoverage of Subacromial Balloon Spacers

InterQual referencedClinical criteria source

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Coverage Summary

This policy (Policy Number CS109TN.W) addresses Surgery of the Shoulder for Tennessee Medicaid and CoverKids and is effective November 1, 2025 (last reviewed November 1, 2025). It applies specifically to Medicaid and CoverKids in the state of Tennessee and defines the circumstances under which shoulder surgical procedures are considered medically necessary.

UnitedHealthcare deems shoulder surgeries medically necessary when clinical coverage criteria are met per the referenced InterQual® CP: Procedures categories (Arthroscopy or Arthroscopically Assisted Surgery, Shoulder; Arthroscopy or Arthroscopically Assisted Surgery, Shoulder (Adolescent); Arthroscopy, Diagnostic, +/- Synovial Biopsy, Shoulder; Joint Replacement, Shoulder; Removal and Replacement or Revision, Joint Replacement, Shoulder). The policy explicitly states that Subacromial Balloon Spacers (SABS) for rotator cuff tears are unproven and not medically necessary due to insufficient evidence of efficacy.

Providers must refer to and document that the procedure meets the applicable InterQual CP: Procedures criteria to support medical necessity for covered shoulder surgeries. Claims for subacromial balloon spacers for treatment of rotator cuff tears are at risk for denial consistent with the policy stance.

Policy Metadata

PayerUnitedHealthcare (Tennessee Medicaid & CoverKids)

PolicySurgery of the Shoulder (for Tennessee Only)

Policy NumberCS109TN.W

Effective DateNovember 1, 2025

Last Review DateNovember 1, 2025

ScopeApplies to Tennessee Medicaid and CoverKids

Coverage stanceMixed — shoulder surgeries covered when InterQual CP criteria met; subacromial balloon spacers (SABS) are unproven and not medically necessary

Medical-Necessity Criteria

Medically Necessary Shoulder Surgery

Covered when ALL of the following are met per referenced InterQual CP Procedures:

Procedure meets medical necessity clinical coverage criteria in InterQual CP: Procedures for one of the listed categories: Arthroscopy or Arthroscopically Assisted Surgery, Shoulder; Arthroscopy or Arthroscopically Assisted Surgery, Shoulder (Adolescent); Arthroscopy, Diagnostic, +/- Synovial Biopsy, Shoulder; Joint Replacement, Shoulder; Removal and Replacement or Revision, Joint Replacement, Shoulder.

Must refer to InterQual criteria for specific clinical criteria and indications.

Subacromial Balloon Spacers (SABS)

Coverage determination:

Subacromial balloon spacers for the treatment of rotator cuff tears are unproven and not medically necessary due to insufficient evidence of efficacy.

Evidence reviews and guidance (Hayes, ECRI, systematic reviews, RCTs, NICE) indicate limited, low-quality, or inconclusive comparative evidence and recommend use only in research or not to use when debridement is suitable.

Coding (referenced procedures)

Referenced CPT codes for shoulder procedures (informational/reference)CPT

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.

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Provider Actions / Billing Impact

Documentation Required

Use InterQual criteria for medical necessity determination

Providers must refer to and document that the procedure meets the applicable InterQual CP: Procedures criteria (listed categories) to support medical necessity for covered shoulder surgeries.

Arthroscopy or Arthroscopically Assisted Surgery, Shoulder
Arthroscopy or Arthroscopically Assisted Surgery, Shoulder (Adolescent)
Arthroscopy, Diagnostic, +/- Synovial Biopsy, Shoulder
Joint Replacement, Shoulder
Removal and Replacement or Revision, Joint Replacement, Shoulder

Denial Risk

SABS not medically necessary

Claims for subacromial balloon spacers for treatment of rotator cuff tears are at risk for denial as the policy states SABS are unproven and not medically necessary.

Background and Evidence Summary

This Tennessee-specific policy references InterQual CP procedure criteria as the source for determining medical necessity for a range of shoulder procedures and notes the addition of the InterQual reference for Removal and Replacement or Revision, Joint Replacement, Shoulder in the current revision.

The policy reviews evidence on biodegradable Subacromial Balloon Spacers (SABS; e.g., the InSpace Subacromial Tissue Spacer System) used to treat massive, irreparable rotator cuff tears and concludes available evidence is insufficient to support coverage. Key evidence summaries (Hayes evolving evidence reviews, ECRI assessment, systematic reviews, and RCT data) indicate minimal or unclear support for InSpace SABS, short-term follow-up in many studies, heterogeneity of study designs, potential industry bias, and lack of long-term comparative effectiveness data.

Notable guidance cited includes the FDA DeNovo classification for the InSpace device (DEN200039) with specific labeled indications and the 2023 NICE Interventional Procedures Guidance (IPG 775), which recommends not using biodegradable subacromial spacers when debridement is a suitable option and otherwise only in research settings, highlighting the need for higher-quality randomized studies with at least 2-year follow-up.

Label	Summary
Hayes reviews (2025a, 2025b, 2022/2023 updates)	Evolving evidence reviews indicate minimal support or unclear support for InSpace SABS; minimal levels of support and very poor quality of available studies—cautious interpretation recommended.
ECRI assessment (2021, updated 2024)	Concluded InSpace is safe and improves function/QOL but comparative evidence is inconclusive; no outcomes reported beyond 2 years; larger RCTs needed.
Key RCT (Verma et al. 2022)	Multicenter single-blinded RCT: InSpace comparable to partial repair at 12 and 24 months, with earlier recovery at 6 weeks; limitations include concomitant procedures and potential bias.
NICE IPG 775 (2023)	Guidance: do not use biodegradable subacromial spacer when debridement is suitable; when debridement not suitable, use only in research; recommend RCTs with ≥2‑year follow-up and experienced multidisciplinary teams/surgeons.

Definitions

SABSSubacromial Balloon Spacers, biodegradable implants intended to treat massive, irreparable rotator cuff tears.

MIRCT / MRCTMassive, irreparable rotator cuff tears.

Medicare / Regulatory Determinations

Determination Type/Name	Number	Effective Date
FDA DeNovo - InSpace Subacromial Tissue Spacer System	DEN200039	2021-06-12

Revision History

11/01/2025material_revisionLatest

Revised medical necessity clinical coverage criteria language: added InterQual CP: Procedures Removal and Replacement or Revision, Joint Replacement, Shoulder; removed references to Arthrotomy, Shoulder and certain TJR Shoulder InterQual entries; archived previous version CS109TN.V.

2025 (Hayes updates)evidence_updateLatest

Updated Clinical Evidence and References sections to reflect current information including Hayes evolving evidence reviews (2025a, 2025b), ECRI update (2024), RCT (Verma et al. 2022), and systematic reviews; concluded evidence for subacromial balloon spacers (InSpace) is insufficient to support routine coverage.