Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for arthroscopy, left shoulder with coracoacromial ligament release (CPT 29826). In a randomized prospective trial with two-year follow-up, Abrams and colleagues concluded that there was no difference in clinical outcomes after rotator cuff repair with or without acromioplasty at two years postoperatively. Familiari and colleagues reported that, A systematic review of the literature does not support the routine use of partial acromioplasty or coracoacromial ligament release in the surgical treatment of rotator cuff disease. In some instances, partial acromioplasty and release of the coracoacromial ligament can result in anterior escape and worsening symptoms. Further research is needed to determine the optimum method for the operative treatment of full-thickness rotator cuff tears. In a meta-analysis, Wang and colleagues noted, Distal clavicle resection in patients with rotator cuff tears did not result in better clinical outcome scores or shoulder range of motion and was not associated with a lower risk of reoperation. Distal clavicle resection might cause acromioclavicular joint instability in patients with rotator cuff tears and concomitant asymptomatic acromioclavicular joint arthritis. Arthroscopic distal clavicle resection is not recommended in patients with rotator cuff tears and concomitant acromioclavicular joint arthritis. Additional well-designed randomized controlled trials with more participants, long-term follow-up, and data on patient-reported outcomes are needed. Rothenberg and colleagues explain, The coracoacromial ligament (CAL) was first described as a pain generator by Dr. Charles Neer in the early 1970s. Since that time, considerable controversy regarding CAL management during acromioplasty has persisted The CAL plays an important role in shoulder biomechanics, joint stability, and proprioception. Morphological variance of the CAL is evident throughout the literature. Age-dependent changes due to chronic stress and cellular degradation cause thickening and stiffening of the CAL that may contribute to a spectrum of shoulder pathology from capsular tightness to rotator cuff tear arthropathy and impingement syndrome. The CAL is an integral component of the coracoacromial arch. CAL release during acromioplasty remains controversial. Future clinical outcomes research should endeavor to advance the understanding of the CAL to refine clinical and intraoperative decision making regarding its management. In this case, the patient was being treated for a torn rotator cuff and adhesive capsulitis of the left shoulder and presented with ongoing symptoms, including pain and weakness. An examination revealed tenderness of the deltoid muscle, with active range of motion noted as 165, 80, 40, and T10, and passive range of motion noted as 175, 150. An empty can was positive on the left and strength in external rotation was noted as 4/5. MRI demonstrated an interval full-thickness tear of the medial fibers of the junction of the supraspinatus and infraspinatus tendons over 14 mm wide by 12 mm, moderate fatty atrophy and strain of the infraspinatus muscle with perifascial fluid, findings suggestive of mild adhesive capsulitis, chronic type 2 SLAP tear, and mild acromioclavicular joint arthrosis and mild narrowing of the subacromial space noted as stable. However, the submitted documentation did not demonstrate any significant pathology to support the additional procedure of CAL release. Given that current medical literature shows that rotator cuff repair can be performed without the additional surgery, and that there is no difference in documented outcomes with or without CAL release, the requested service is not medically indicated. Therefore, arthroscopy, left shoulder with coracoacromial ligament release (CPT 29826), is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert 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.