HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 

Medical Policy:
S-259-001
Topic:
Shoulder Arthroplasty (Total, Hemi, Reverse)/Arthrodesis
Section:
Surgery
Effective Date:
October 1, 2018
Issued Date:
October 1, 2018
Last Revision Date:
April 2018
Annual Review:
April 2018
 
 

Hemi-arthroplasty involves replacing the humeral head and not replacing the glenoid (socket), which is typically the best option if the glenoid does not have any arthritis or if there is some concern that the glenoid component might fail if it is replaced.

Total shoulder arthroplasty involves replacing the humeral head and the glenoid. A total shoulder arthroplasty is typically the best option if the glenoid is damaged, but sufficient bone and rotator cuff remain to ensure that the glenoid component will last.

Reverse shoulder arthroplasty involves replacing both the humeral head and the glenoid, but the ball and socket are reversed to improve muscle function. This allows the deltoid muscle, which has a longer movement arm, to generate greater force, allowing it to act in place of an inadequate functioning or torn rotator cuff.

Revision shoulder surgery involves surgical reconstruction or replacement due to failure or complication of previous shoulder arthroplasty.

Shoulder resurfacing is a surgical procedure that involves replacing the diseased part of the shoulder joint without replacing the humeral head. Resurfacing of the humeral head involves a prosthetic metal covering or cap to provide complete or partial coverage. It can be performed alone (hemi-resurfacing) or in combination with glenoid resurfacing (total or partial shoulder resurfacing).

Shoulder arthrodesis is a surgical resection and fusion of the shoulder (glenohumeral) joint.

Non-surgical care, with regard to the treatment of the shoulder, is defined as any nonsurgical treatment, which has been demonstrated in the scientific literature as efficacious and/or is considered standard of care in the treatment of shoulder pain or loss of function. The types of treatment involved can include, but are not limited to: Ice, relative rest/activity modification, manual therapy, therapy modalities, supervised therapeutic exercise, oral medication, bracing and/or injections (steroid).

Policy Position Coverage is subject to the specific terms of the member's benefit plan.

Hemi-arthroplasty (Replacement) (underline)

Hemi-arthroplasty may be considered medically necessary for the treatment of ANY of the following resulting in severe pain and loss of function:

·         Proximal humerus fracture not amenable to internal fixation; or

·         Destructive degenerative joint disease (i.e., rheumatoid arthritis or osteoarthritis) resulting in marked narrowing of the joint space; or

·         Arthritic conditions in which the glenoid bone stock is inadequate to support a glenoid prosthesis; or

·         Rotator cuff tear arthropathy (severe rotator cuff tearing and end-stage arthritic disease); or

·         Osteonecrosis without glenoid involvement.

When ALL of the following criteria have been met:

·         Chronic severe disabling pain for at least six (6) months in duration; and

·         Loss of shoulder function which interferes with the ability to carry out age appropriate activities of daily living and/or demands of employment; and

·         Failure of non-surgical management for at least six (6) weeks in duration; and

·         No history of active joint infection; and

·         No current systemic infection; and

·         No paralytic disorder of the shoulder; and

·         Radiographic imaging and/or an advanced diagnostic procedure (i.e., MRI, CT scan, etc.), is conclusive for underlying pathology (i.e., as stated above), and correlates with the individual’s reported symptoms and physical exam findings.

Total Shoulder Arthroplasty (Replacement) (underline)

Total Shoulder Arthroplasty may be considered medically necessary for the treatment of:

Destructive degenerative joint disease (rheumatoid arthritis, osteoarthritis, avascular necrosis) resulting in marked narrowing of the joint space or other findings, consistent with advanced degenerative change including one or more of the following:

·         Irregular joint surfaces; or

·         Glenoid sclerosis Osteophyte changes; or

·         Flattened glenoid; or

·         Cystic changes in the humeral head.

That has resulted in severe pain and loss of function and when ALL of the following criteria have been met:

·         Chronic severe disabling pain for at least six (6) months in duration; and

·         Loss of shoulder function which interferes with the ability to carry out age appropriate activities of daily living and/or demands of employment; and

·         Failure of non-surgical management for at least six (6) weeks in duration; and

·         There is no history of active joint infection; and

·         There is no current systemic infection; and

·         Radiographic imaging and/or an advanced diagnostic procedure (i.e., MRI, CT scan), which is conclusive for underlying pathology (i.e., as stated above), and correlates with the individual’s reported symptoms and physical exam findings.

Reverse Shoulder Arthroplasty (Replacement) (underline)

Reverse Shoulder Arthroplasty may be considered medically necessary for treatment of

ANY of the following indications:

·         Deficient rotator cuff with severe glenohumeral arthropathy and limited ability to actively flex the upper extremity to 90º against gravity; or

·         Failed hemi-arthroplasty; or

·         Failed total shoulder replacement with a deficient rotator cuff that is nonrepairable; or

·         Required reconstruction after a tumor resection; or

·         Shoulder fracture that is not repairable or cannot be reconstructed with other techniques.

That has resulted in severe pain and loss of function and when ALL of the following criteria have been met:

·         Chronic severe disabling pain for at least six (6) months in duration; and

·         Loss of shoulder function which interferes with the ability to carry out age appropriate activities of daily living and/or demands of employment; and

·         Failure of non-surgical management for at least six (6) weeks in duration; and

·         Affected joint must be anatomically and structurally suited (i.e., residual bone allows for firm fixation of implant) to receive the selected implant(s); and

·         The individual must possess functional use of the deltoid muscle; and

·         At least 90º of passive shoulder range of motion (elevation/flexion); and

·         No active or local infection; and

·         No condition that would place excessive stress on the implant (i.e., Charcot’ joint).

Reverse shoulder arthroplasty for any other indication is considered experimental/investigational, and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Shoulder Resurfacing(underline)

Shoulder Resurfacing, including total, hemi or partial resurfacing, is considered E/I, and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Shoulder Revision(underline)

Shoulder Revision may be considered medically necessary when ALL of the following criteria have been met:

·         Previous partial or total shoulder arthroplasty; and

·         Chronic severe, disabling pain; and

·         Loss of function which interferes with the ability to carry out age appropriate activities of daily living and/or demands of employment; and

·         One or more of the following:

o    Fracture or dislocation

o    Instability of the components

o    Aseptic loosening

o    Infection

o    Periprosthetic fracture

o    Unexplained pain for greater than six (6) months not responsive to non- surgical management.

Shoulder Revision is considered not medically necessary when EITHER of the following is present:

·         Persistent infection; and

·         Poor bone quality.

Shoulder Arthrodesis(underline)

Shoulder Arthrodesis may be considered medically necessary for ANY of the following indications:

·         Irreparable deltoid and rotator cuff deficiency; or

·         Failed total shoulder arthroplasty; or

·         Joint infection; or

·         Reconstruction after tumor resection; or

·         Brachial plexus palsy; or

·         Recurrent shoulder instability, which has failed previous repair/reconstruction; or

·         Paralytic disorder in infancy.

That has resulted in severe pain and loss of function and when ALL of the following criteria have been met:

·         Chronic severe, disabling pain; and

·         Loss of shoulder function which interferes with the ability to carry out age appropriate activities of daily living and/or demands of employment; and

·         Failure of non-surgical management for at least six to eight (6-8) weeks in duration or is not a candidate for alternative treatments; and

·         Radiographic imaging and/or and advanced diagnostic procedure (i.e., MRI, CT scan, etc.), which is conclusive for underlying pathology and correlates with the individual’s reported symptoms and physical exam findings.

Shoulder Arthrodesis is considered not medically necessary for ANY of the following:

·         Deficient functional scapulothoracic motion; or

·         Paralysis of the trapezius, levator, scapulae and serratus anterior; or

·         Charcot arthropathy; or

·         Advanced age and frailty; or

·         Progressive neurologic disease.

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Place of Service: Inpatient/Outpatient



The policy position applies to all commercial lines of business


Denial Statements

Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

Services that do not meet the criteria of this policy will be considered experimental/investigational (E/I). A network provider can bill the member for the experimental/investigational service. The provider must give advance written notice informing the member that the service has been deemed E/I. The member must be provided with an estimate of the cost and the member must agree in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.



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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

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The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

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    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

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    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

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