Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for joint manipulation under anesthesia. Catalano and colleagues noted, The stiff digit may be a consequence of trauma or surgery to the hand and fingers and can markedly affect a patients level of function and quality of life. Stiffness and contractures may be caused by one or a combination of factors, including joint, intrinsic, extensor, and flexor tendon pathology, and the patients individual biology. A thorough understanding of the anatomy, function, and relationship of these structures on finger joint range of motion is crucial for interpreting physical examination findings and preoperative planning. For most cases, nonsurgical management is the initial step and consists of hand therapy, static and dynamic splinting, and/or serial casting, whereas surgical management is considered for those with more extensive contractures or for those that fail to improve with conservative management. Assuming no bony block to motion, surgery consists of open joint release, tenolysis of flexor and/or extensor tendons, and external fixation devices. Outcomes after treatment vary depending on the joint involved along with the severity of contracture and the patients compliance with formal hand therapy and a home exercise program. In this case, the patient was being treated for amyotrophic lateral sclerosis. They underwent a palmaris longus opponensplasty with intrinsic reconstruction of the index and middle finger and revision opponensplasty. Prior to the revision surgery, the patient had undergone extensive occupational therapy with noted trial of spica splinting and static progressive splinting. The patient was noted to have developed scarring in the intrinsic muscles of the index and middle fingers resulting in limitation in full finger flexion of the index finger and limitation in the ability to open a cup and extend the fingers at the metacarpal phalangeal joint. Therapy notes demonstrate continued, persistent stiffness in the middle and index fingers proximal interphalangeal joint. A manipulation was performed at the time of the revision opponensplasty. Therefore, joint manipulation under anesthesia was likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was likely to be more beneficial than any available standard method of evaluation for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer 1 is board certified in orthopedic surgery with experience in hand surgery, reviewer 2 is board certified in plastic surgery with subspecialty certification in surgery of the hand, and reviewer 3 is board certified in plastic surgery with experience in hand surgery. All reviewers are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.