Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve the thread carpal tunnel release surgery (64999) and echo guidance for biopsy (76942).You asked the Plan to pre-approve these services. You say that these services are medically necessary for the enrollee.The Plan denied your request. The Plan says that these services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee was being treated for bilateral carpal tunnel syndrome; primary osteoarthritis of the bilateral first carpometacarpal joints; pain in both wrists; paresthesia of both hands; and trigger middle finger of the left hand. She presented with bilateral hand numbness and tingling. She has had these symptoms for four years with left hand symptoms being worse. The enrollee notes that over the past six months the symptoms have been worsening and have been more constant. There is numbness and tingling in the median nerve sensory distribution. She has significant loss of sensation and difficulty with normal activities like buttoning clothes with her right hand. There is nocturnal worsening of numbness and tingling. There is worsening of pain while holding or gripping and she is dropping objects. The exam revealed Tinel's and Phalen's are positive bilaterally. There is mild to moderate right-sided and mild left-sided thenar atrophy. The thumb grind test is positive on the right side. The documentation is evident regarding the clinical and electrodiagnostic carpal tunnel condition of the left wrist. The condition is associated with worsening high level painful symptoms, nocturnal painful tingling and thenar atrophy. There has been a trial and failure of reasonable and comprehensive less invasive conservative care measures including restricted activities, with medications and splinting. The well-established diagnosis has clearly failed less invasive treatment. The presence of thenar atrophy further supports the severity and relative urgency of more definitive treatment, including the requested procedure. Furthermore, there is now sufficient literature of procedure safety and efficacy. Therefore, the request for thread carpal tunnel release (64999) and echo guidance for biopsy (76942) is medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have been met.Therefore, we decided that the Plan has to pre-approve the thread carpal tunnel release surgery (64999) and echo guidance for biopsy (76942).If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.