Appeal type: Medical necessity
Decision: Upheld

Diagnosis: SLAP Tear (superior labrum anterior and posterior)

Treatment anchoring of the biceps tendon; extensive removal of abnormal shoulder joint tissue using endoscope; release or removal of shoulder scar tissue using an endoscope, repair of shoulder rotator cuff using an endoscope; shaving of shoulder bone using an endoscope

The insurer denied coverage for anchoring of the biceps tendon; extensive removal of abnormal shoulder joint tissue using endoscope; release or removal of shoulder scar tissue using an endoscope, repair of shoulder rotator cuff using an endoscope; shaving of shoulder bone using an endoscope

The denial is upheld

This patient has a history of carpometacarpal arthritis, carpal tunnel syndrome, and a right shoulder injury. He presented to the Orthopedic Surgeon's office for the evaluation of a right biceps injury. The patient was previously treated for a partial rotator cuff tear. X-rays of the right shoulder revealed no fracture or dislocation. The physician recommended anchoring of the biceps tendon; extensive removal of abnormal shoulder joint tissue using endoscope; release or removal of shoulder scar tissue using an endoscope, repair of shoulder rotator cuff using an endoscope; shaving of shoulder bone using an endoscope to treat the patient's shoulder injury. The patient had a right shoulder arthroscopy, extensive debridement, and open subpectoral biceps tenodesis. 

The records show an acute traumatic event occurred. The patient sustained a new proximal biceps tendon rupture. He reported lifting and subsequent pop. He was found to have a deformity consistent with proximal detachment of the structure. He had tenderness, weakness and ecchymosis which is found with biceps tendon ruptures. An MRI (Magnetic Resonance Image) report showed the pathology. 

The management of a proximal biceps tendon rupture should take into consideration the age and activity of the individual. 

Scientific literature and National Guidelines do not recommend immediate surgery. Most people are able to return to functional use with the deformity. A period of conservative management has been recommended prior to surgical intervention. This was not noted in the submitted documentation. 

AIM (Advance Imaging Management) Clinical Criteria for Biceps Tendon Injury

Tendinopathy of the long head of the biceps
"Biceps tenodesis or tenotomy may be considered medically necessary for shoulder pain when All of the following criteria are met:

Pain in the front of the shoulder and/or clicking, popping or catching sensation when using the arm and shoulder, MET

 Clinical exam is consistent with long head of biceps pathology (at least 2 of the following: anterior shoulder pain, weakness, tenderness over the biceps groove, pain in the anterior shoulder during resisted supination of the forearm [Yergason test], positive Speed test) MET
 MRI findings consistent with biceps tendinopathy or AIM criteria met for SLAP (superior labrum anterior and posterior) tear, MET

 Failure of at least 12 weeks of conservative management or at least 6 weeks when AIM criteria for rotator cuff tear are met, NOT MET. No conservative management had been provided." 

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.

Anchoring of the biceps tendon; extensive removal of abnormal shoulder joint tissue using endoscope; release or removal of shoulder scare tissue using an endoscope, repair of shoulder rotator cuff using an endoscope; shaving of shoulder bone using an endoscope is not considered medically necessary for this patient.

The insurer's denial of coverage for anchoring of the biceps tendon; extensive removal of abnormal shoulder joint tissue using endoscope; release or removal of shoulder scar tissue using an endoscope, repair of shoulder rotator cuff using an endoscope; shaving of shoulder bone using an endoscope is upheld. Medical Necessity is not substantiated.