Description
General Information
It is an expectation that all patients receive care/services from a licensed clinician. All appropriate supporting documentation, including recent pertinent office visit notes, laboratory data, and results of any special testing must be provided. If applicable: All prior relevant imaging results and the reason that alternative imaging cannot be performed must be included in the documentation submitted.

Purpose
This guideline addresses elective, non-emergent shoulder arthroplasty (shoulder replacement) procedures, including total shoulder arthroplasty, reverse shoulder arthroplasty, resurfacing arthroplasty, partial shoulder replacement or hemiarthroplasty, and revision arthroplasty procedures.

Scope
Arthroplasty procedures are reserved for end stage arthritis of the shoulder joint, including functional loss of motion, pain, and disability. The choice of arthroplasty is dependent upon surgeon philosophy, experience, and skill. Successful outcome, regardless of procedure, is more likely with high volume (> 20 per year) shoulder specialists.

GENERAL REQUIREMENTS
Elective surgery of the shoulder may be considered if the following general criteria are met:

• Clinical correlation of individual’s subjective complaints with objective exam findings and/or imaging (when applicable)
• Individual has limited function (age-appropriate activities of active daily livings (ADLs), occupational, or athletic)
• Individual does not have an active local or systemic infection
• Individual does not have active, untreated drug dependency (including but not limited to narcotics, opioids, muscle relaxants) unless engaged in treatment
• Individual has good oral hygiene and does not have major dental work scheduled or anticipated (ideally within one year of joint replacement; due to increased post-surgical infection risk)
• Individual is medically stable and optimized for surgery, and any treatable comorbidities are adequately medically managed such as diabetes, nicotine addiction, or an excessively high BMI. There should also be a shared decision between the patient and physician to proceed with a total joint replacement when comorbidities exist as it pertains to the added risk of complications ^(1,2)

Clinical notes should address:

• Symptom onset, duration, and severity
• Loss of function and/or limitations
• Type and duration of non-operative management modalities

Non-operative management, when required, will be specified within the clinical indications below and may include one or more of the following:

• Physical therapy or properly instructed home exercise program
• Rest or activity modification
• Application of heat or ice
• Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, analgesics
• Corticosteroid injections

Policy
INDICATIONS
Total Shoulder Arthroplasty (TSA)
Total Shoulder Arthroplasty may be necessary when the following criteria are met ^(1,3,4):

• Evidence of painful osteoarthritis or inflammatory, non-infectious arthritis (e.g., rheumatoid) with functional limitations such as ADLs, employment, or recreation
• Functional and intact rotator cuff and deltoid (adequate abduction strength); confirmed by physical examination, MRI, or CT scan
• Complete or near-complete loss of joint space* on axillary or AP X-rays (internal rotation and/or external rotation)*

*NOTE: In those with bone-on-bone articulation on axillary or true AP X-rays, non-operative treatment is not required
NOTE: MRI should not be the primary imaging study to determine the extent of disease

• Failure of at least 12 weeks of non-operative treatment that includes at least ONE of the following:
  • Physical therapy or properly instructed home exercise program
  • Rest or activity modification
  • Application of heat or ice
  • Pharmacologic treatment (oral/topical NSAIDS, acetaminophen, analgesics)
  • Corticosteroid injections
• No cortisone injection into the joint within 12 weeks of surgery ^(1,5,6,7,8)
• No prior arthroscopic surgery of the shoulder within 12 weeks of surgery ^(9,10)

Contraindications

• Neurological disease resulting in complex regional pain syndrome (CRPS or its variants), Charcot arthropathy, or loss of deltoid or rotator cuff function
• Active infection or any infection within 12 weeks of surgery:
  • History of prior shoulder joint infection without documentation that indolent infection has been eliminated (individual has been off antibiotics for a minimum of 6 weeks). Evidence of resolved infection should include laboratory work (serologies, including CBC with differential, ESR (erythrocyte sedimentation rate), CRP (C-reactive protein), with or without blood cultures, soft tissue biopsy cultures, or synovial fluid aspiration (cultures, gram stain, cell count, differential, crystals). Cultures should be for aerobic and anaerobic bacteria (AFB, fungal), with special attention to the possibility of Cutibacterium acnes (C. acnes) formerly Propionibacterium acnes (P. acnes). (6,11)
• Poor dental hygiene (e.g., tooth extraction should be performed prior to arthroplasty). Major dental work within 2 years after a joint replacement MAY lead to seeding of the implant and possible revision surgery. If possible, all dental work must be completed prior to shoulder arthroplasty as these procedures increase risk for infection
• Any cortisone injection into the joint within 12 weeks of surgery ^(1,5,6,7,8)
• Arthroscopic surgery of the shoulder within 12 weeks of surgery ^(9,10)

Hemiarthroplasty
Hemiarthroplasty may be necessary when the following criteria are met ^(3,4):

• Acute 3 or 4-part fracture of the proximal humerus

OR

• Individual meets all of the criteria for a Total Shoulder Arthroplasty, as detailed above, or has avascular necrosis or osteonecrosis of the humeral head without advanced glenoid disease
• No cortisone injection into the joint within 12 weeks of surgery ^(1,5,6,7,8)
• No prior arthroscopic surgery of the shoulder within 12 weeks of surgery ^(9,10)

Contraindications

• Any cortisone injection into the joint within 12 weeks of surgery ^(1,5,6,7,8)
• Arthroscopic surgery of the shoulder within 12 weeks of surgery ^(9,10)
• Neurologic disease resulting in CRPS or Charcot shoulder
• Active infection within 12 weeks of surgery

Reverse Total Shoulder Arthroplasty (RTSA)
For the treatment of arthritis, irreparable rotator cuff tears or proximal humeral fractures ^(12,13):

Arthritis
RTSA may be indicated for the treatment of arthritis when ALL of the following criteria are met ⁽¹²⁾:

• Evidence of painful osteoarthritis or inflammatory, non-infectious arthritis (e.g., rheumatoid) with functional limitations (such as activities of daily living or employment or simple recreation)
• Age > 60; requests for RTSA in individuals < 60 will be reviewed on a case-by-case basis*
• Complete or near-complete loss of joint space on axillary or AP x-rays (internal rotation and/or external rotation) OR radiographic evidence of advanced glenoid bone loss or excessive retroversion*

*In those with bone-on-bone articulation on axillary or true AP X-rays, non-operative treatment is not required.

NOTE: MRI should not be the primary imaging study to determine the extent of disease

• Non-repairable massive tears involving at least two tendons, substantial partial, OR focal full thickness rotator cuff tear with significant rotator cuff dysfunction (weakness, impingement signs on exam) AND intact deltoid
• Requests for reverse TSA for advanced glenohumeral arthritis with an intact rotator cuff will be reviewed on a case-by-case basis ^(14,15)
• Failure of at least 12 weeks of non-operative treatment that includes at least ONE of the following:
  • Physical therapy or properly instructed home exercise program
  • Rest or activity modification
  • Application of heat or ice
  • Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, analgesics
  • Corticosteroid injections
• No cortisone injection into the joint within 12 weeks of surgery ^(1,5,6,7,8)
• No prior arthroscopic surgery of the shoulder within 12 weeks of surgery ^(9,10)

*NOTE: RTSA has been found to be a reliable operation in younger individuals with improvement in pain, range of motion and strength, without a large number of early failures ^(12,16,17)
Contraindications ⁽¹²⁾

• Any cortisone injection into the joint within 12 weeks of surgery ^(1,5,6,7,8)
• Active infection within 12 weeks of surgery
• Neurologic disease resulting in CRPS or Charcot shoulder
• Arthroscopic surgery of the shoulder within 12 weeks of surgery ^(9,10)

Proximal Humeral Fractures
RTSA may be indicated for the treatment of fractures when ALL of the following criteria are met:
Acute 2, 3, or 4-part fractures of proximal humerus with or without concomitant tuberosity as evidence by radiographic findings OR painful malunion of proximal humerus fracture with rotator cuff dysfunction (weakness, impingement signs on exam) ⁽¹²⁾
Age > 60; requests for RTSA in individuals < 60 will be reviewed on a case-by-case basis

Rotator Cuff Tears
RTSA may be indicated for the treatment of irreparable rotator cuff tears in the absence of arthritis when ALL of the following criteria are met:

• Non-repairable massive rotator cuff tear 
• Intact deltoid
• Inability to actively elevate the arm above the level of the shoulder (90 degrees) (i.e., pseudoparalysis); OR history of previous failed rotator cuff repair with severe pain and functional disability ^(12,18)
• Age > 60; requests for RTSA in individuals < 60 will be reviewed on a case-by-case basis
• Failure of at least 12 weeks of attempted physical therapy or properly instructed home exercise program unless there is worsening of symptoms (19,20,21)
• No arthroscopic surgery of the shoulder within 12 weeks of surgery ^(9,10)
• No cortisone injection into the joint within 12 weeks of surgery ^(1,5,6,7,8)

Contraindications

• Any cortisone injection into the joint within 12 weeks of surgery ^(1,5,6,7,8)
• Active infection within 12 weeks of surgery
• Neurologic disease resulting in CRPS or Charcot shoulder
• Arthroscopic surgery of the shoulder within 12 weeks of surgery ^(9,10)

NOTE: RTSA is a reasonable surgical option for irreparable rotator cuff repair without arthritis. However, caution should be exercised when offering RTSA to individuals without pseudoparalysis because they can have a higher complication and dissatisfaction rate ^(22,23)

Revision Arthroplasty (See Contraindications*) ^(24,25)
There are six primary indications for revision shoulder arthroplasty:

1. Conversion of a hemiarthroplasty to a total shoulder arthroplasty
2. Conversion of a hemiarthroplasty to a reverse shoulder arthroplasty
3. Revision of a total shoulder arthroplasty to another total shoulder arthroplasty
4. Revision of a total shoulder arthroplasty to a reverse shoulder arthroplasty
5. Revision of a reverse total shoulder arthroplasty to another reverse shoulder arthroplasty
6. Revision of a total shoulder or reverse shoulder arthroplasty to a hemiarthroplasty

Conversion of a Hemiarthroplasty to a Total Shoulder Arthroplasty 
May be necessary when ALL of the following criteria are met: 

• Evidence of a prior hemiarthroplasty
• Persistent pain and functional loss
• Documentation of mechanical failure, or component failure/malposition OR negative infection evaluation (including CRP, ESR, with or without negative aspiration). If these markers are elevated, a clear statement by the treating surgeon is required regarding the surgical plan to rule out infection.
• Clinical and radiographic evidence of intact rotator cuff (or repairable rotator cuff tear), including ONE of the following two options:
  • Radiographic evidence of failed humeral component, including aseptic loosening or periprosthetic fracture (documentation should include radiolucencies around cemented or uncemented components) OR
  • Clinical and radiographic evidence of glenoid articular cartilage disease (including progressive arthritis)

Conversion of a Hemiarthroplasty to a Reverse Shoulder Arthroplasty 
May be necessary when ALL of the following criteria are met:

• Evidence of a prior hemiarthroplasty
• Persistent pain and functional loss
• Documentation of mechanical failure, or component failure/malposition OR negative infection evaluation (including CRP, ESR, with or without negative aspiration). If these markers are elevated, a clear statement by the treating surgeon is required regarding the surgical plan to rule out infection.
• Intact deltoid and intact axillary nerve
• Age > 60; requests for individuals < 60 will be reviewed on a case-by-case basis
• Evidence of pseudoparalysis (inability to elevate arm) OR severe pain with elevation

Revision of a Total Shoulder Arthroplasty to Another Total Shoulder Arthroplasty 
May be necessary when ALL of the following criteria are met:

• Evidence of prior total shoulder arthroplasty
• Persistent pain and functional loss
• Documentation of mechanical failure, or component failure/malposition OR negative infection evaluation (including CRP, ESR, with or without negative aspiration). If these markers are elevated, a clear statement by the treating surgeon is required regarding the surgical plan to rule out infection.
• Intact deltoid and intact axillary nerve
• Clinical and radiographic evidence of intact rotator cuff (or repairable rotator cuff tear)
• Radiographic evidence of failed humeral and/or glenoid component, including aseptic loosening or periprosthetic fracture

Revision of a Total Shoulder Arthroplasty to a Reverse Shoulder Arthroplasty 
May be necessary when ALL of the following criteria are met:

• Evidence of prior total shoulder arthroplasty
• Persistent pain and functional loss
• Documentation of mechanical failure, or component failure/malposition OR negative infection evaluation (including CRP, ESR, with or without negative aspiration). If these markers are elevated, a clear statement by the treating surgeon is required regarding the surgical plan to rule out infection.
• Intact deltoid function
• Age > 60 (requests in individuals < 60 will be reviewed on a case-by-case basis)
• Evidence of pseudoparalysis (inability to elevate arm) OR severe pain with elevation

Revision of a Reverse Shoulder Arthroplasty to Another Reverse Shoulder Arthroplasty 
May be necessary when ALL of the following criteria are met:

• All cases should be reviewed on a case-by-case basis and include the following:
  • Evidence of prior reverse shoulder arthroplasty
  • Persistent pain and functional loss
  • Documentation of mechanical failure, or component failure/malposition OR negative infection evaluation (including CRP, ESR, with or without negative aspiration). If these markers are elevated, a clear statement by the treating surgeon is required regarding the surgical plan to rule out infection.
  • Radiographic evidence of failed humeral and/or glenoid component, including aseptic loosening or periprosthetic fracture
  • Intact deltoid

Revision of a Total Shoulder or Reverse Shoulder Arthroplasty to a Hemiarthroplasty 
May be necessary when ALL of the following criteria are met

• All cases should be reviewed on a case-by-case basis and include the following:
  • Evidence of prior total shoulder or reverse shoulder arthroplasty
  • Persistent pain and functional loss
  • Documentation of mechanical failure, or component failure/malposition OR negative infection evaluation (including CRP, ESR, with or without negative aspiration). If these markers are elevated, a clear statement by the treating surgeon is required regarding the surgical plan to rule out infection.
  • Radiographic evidence of failed humeral and/or glenoid component, including aseptic loosening or periprosthetic fracture
  • Intact deltoid and intact axillary nerve
  • Insufficient glenoid bone to support a revision glenoid component

*Contraindications for Revision Arthroplasty

• Active or recent history of infection
• Neurogenic pain syndrome
• Acromial fracture OR overly thin acromion from prior subacromial decompression
• Severe osteoporosis as evidenced by radiographic osteopenia, osteomalacia or severe osteoporosis on DXA scan
• Non-functioning deltoid or axillary nerve injury/palsy
• Any arthroscopic surgery of the shoulder within 12 weeks of surgery ^(9,10)
• Any cortisone injection into the joint within 12 weeks of surgery ^(1,5,6,7,8)

References

1. Razmjou H, Christakis M, Nam D, Drosdowech D, Sheth U et al. Assessing Appropriateness for Shoulder Arthroplasty Using a Shared Decision-Making Process. Journal of Shoulder and Elbow Arthroplasty. 2023; 7: 247154922311671. 10.1177/24715492231167104. 
2. Seok H, Park J, Park S. Risk Factors for Periprosthetic Joint Infection after Shoulder Arthroplasty: Systematic Review and Meta-Analysis. Journal of Clinical Medicine. 2022; 11: 10.3390/jcm11144245. 
3. Hughes J, Athwal G, Aibinder W, Wiater J. Shoulder Joint Replacement. American Academy of Orthopaedic Surgeons. 2024; Accessed: 09/26/2024. https://orthoinfo.aaos.org/en/treatment/shoulder-joint-replacement/#:~:text=Shoulder%20replacement%20surgery%20was%20first%20performed%20in%20the. 
4. Mattei L, Mortera S, Arrigoni C, Castoldi F. Anatomic shoulder arthroplasty: an update on indications, technique, results and complication rates. Joints. 2015; 3: 72-7. 10.11138/jts/2015.3.2.072. 
5. Lucenti L, Panvini F, de Cristo C, Rapisarda D, Sapienza M et al. Do Preoperative Corticosteroid Injections Increase the Risk of Infection after Shoulder Arthroscopy or Shoulder Arthroplasty? A Systematic Review. Healthcare (Switzerland). 2024; 12: 10.3390/healthcare12050543. 
6. Markes A, Bigham J, Ma C, Iyengar J, Feeley B. Preventing and Treating Infection in Reverse Total Shoulder Arthroplasty. Current Reviews in Musculoskeletal Medicine. 2023; 16: 371-380. 10.1007/s12178-023-09843-1. 
7. Stadecker M, Gu A, Ramamurti P, Fassihi S, Wei C et al. Risk of revision based on timing of corticosteroid injection prior to shoulder arthroplasty. The bone & joint journal. 2022; 104-B: 620-626. 10.1302/0301-620X.104B5.BJJ-2021-0024.R3. 
8. Werner B, Cancienne J, Burrus M, Griffin J, Gwathmey F. The timing of elective shoulder surgery after shoulder injection affects postoperative infection risk in Medicare patients. Journal of Shoulder and Elbow Surgery. 2016; 25: 390-397. 10.1016/j.jse.2015.08.039. 
9. Malik A, Morris J, Bishop J, Neviaser A, Khan S. Undergoing an Arthroscopic Procedure Prior to Shoulder Arthroplasty is Associated With Greater Risk of Prosthetic Joint Infection. Arthroscopy - Journal of Arthroscopic and Related Surgery. 2021; 37: 1748-1754.e1. 10.1016/j.arthro.2021.01.013. 
10. Wright-Chisem J, Apostolakos J, Dines J, Dines D, Gulotta L et al. The impact of prior ipsilateral arthroscopy on infection rates after shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2021; 30: 1596-1602. 10.1016/j.jse.2020.09.019. 
11. Elston M, Dupaix J, Opanova M, Atkinson R. Cutibacterium acnes (formerly Proprionibacterium acnes) and Shoulder Surgery. Hawai’i journal of health & social welfare. 2019; 78: 3-5. 
12. Familiari F, Rojas J, Doral M, Huri G, McFarland E. Reverse total shoulder arthroplasty. EFORT Open Reviews. 2018; 3: 58-69. 10.1302/2058-5241.3.170044. 
13. Hermana S, Rednam M. Reverse Shoulder Arthroplasty [Updated 2024 Mar 13. Stat Pearls Publishing. 2024; Accessed: 09/26/2024. https://www.ncbi.nlm.nih.gov/books/NBK574545. 
14. Heifner J, Kumar A, Wagner E. Glenohumeral osteoarthritis with intact rotator cuff treated with reverse shoulder arthroplasty: a systematic review. Journal of Shoulder and Elbow Surgery. 2021; 30: 2895-2903. 10.1016/j.jse.2021.06.010. 
15. Nazzal E, Reddy R, Como M, Rai A, Greiner J et al. Reverse shoulder arthroplasty with preservation of the rotator cuff for primary glenohumeral osteoarthritis has similar outcomes to anatomic total shoulder arthroplasty and reverse shoulder arthroplasty for cuff arthropathy. Journal of Shoulder and Elbow Surgery. 2023; 32: S60-S68. 10.1016/j.jse.2023.02.005. 
16. Goldenberg B, Samuelsen B, Spratt J, Dornan G, Millett P. Complications and implant survivorship following primary reverse total shoulder arthroplasty in patients younger than 65 years: a systematic review. Journal of Shoulder and Elbow Surgery. 2020; 29: 1703-1711. 10.1016/j.jse.2020.02.004. 
17. Otto R, Clark R, Frankle M. Reverse shoulder arthroplasty in patients younger than 55 years: 2- to 12-year follow-up. Journal of Shoulder and Elbow Surgery. 2017; 26: 792-797. 10.1016/j.jse.2016.09.051. 
18. Weber S, Chahal J. Management of Rotator Cuff Injuries. Journal of the American Academy of Orthopaedic Surgeons. 2020; 28: E193-E201. 10.5435/JAAOS-D-19-00463. 
19. Christensen B, Andersen K, Rasmussen S, Andreasen E, Nielsen L. Enhanced function and quality of life following 5 months of exercise therapy for patients with irreparable rotator cuff tears - An intervention study. BMC Musculoskeletal Disorders. 2016; 17: 10.1186/s12891-016-1116-6. 
20. Juhan T, Stone M, Jalali O, Curtis W, Prodromo J et al. Irreparable rotator cuff tears: Current treatment options. Orthopedic Reviews. 2019; 11: 123-128. 10.4081/or.2019.8146. 
21. Shepet K, Liechti D, Kuhn J. Nonoperative treatment of chronic, massive irreparable rotator cuff tears: a systematic review with synthesis of a standardized rehabilitation protocol. Journal of Shoulder and Elbow Surgery. 2021; 30: 1431-1444. 10.1016/j.jse.2020.11.002. 
22. Monir J, Tams C, Wright T, Parsons M, King J. Preoperative factors associated with loss of range of motion after reverse shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2021; 30: e621-e628. 10.1016/j.jse.2021.02.010. 
23. Virk M, Nicholson G, Romeo A. Irreparable Rotator Cuff Tears Without Arthritis Treated With Reverse Total Shoulder Arthroplasty. The Open Orthopaedics Journal. 2018; 10: 296-308. 10.2174/1874325001610010296. 
24. Harrison A, Knudsen M, Braman J. Hemiarthroplasty and Total Shoulder Arthroplasty Conversion to Reverse Total Shoulder Arthroplasty. Current Reviews in Musculoskeletal Medicine. 2020; 13: 501-508. 10.1007/s12178-020-09649-5. 
25. Mauch F, Huth J. Revision of anatomic shoulder arthroplasty. Orthopadie. 2023; 52: 137-143. 10.1007/s00132-022-04337-3.

Coding Section

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

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