Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Anterior joint instability
 
Treatment:  Right Shoulder Arthroscopy with Stabilization of the Anterior Superior Capsulolabral repair

The insurer denied the Surgical Services.  The denial was reversed.

This case involves a middle aged male patient who had a Magnetic Resonance Imaging (MRI) of the right shoulder performed in late 2018.  The impression revealed findings compatible with anterior joint instability, as well as nonacute Hill-Sachs deformity, which measures approximately 2.5 x 0.5 x 2.0 cm.  There was focal flattening of the anteroinferior glenoid with no measurable bone loss.  There was also a tear through the chondrolabral junction of the anteroinferior labrum.  The patient was seen in the clinic in late 2018 for evaluation of the right shoulder.  The patient sustained a shoulder injury several years earlier.  He had over 15 dislocations that had been happening for years, now with everyday activity.  He was able to self-reduce the dislocation.  He had completed several rounds of physical therapy.  He reported that he was not currently taking any pain medication, when present it was dull and rated 1-2/10 on the pain scale.  He reported that he had never had injections to the shoulder.  Examination of the right shoulder revealed evidence of deformity, atrophy and asymmetry.  There was active range of motion in forward flexion to 170 degrees, abduction to 170 degrees, external rotation to 50 degrees and internal rotation to the T12 level.  Passive range of motion had similar parameters, and the shoulder was unstable to applied stress.  The patient had 5/5 rotator cuff strength when tested.  The patient had a mildly positive Hawkins test.  The treatment recommendation was right shoulder arthroscopy with anterior labral repair/stabilization.  In late 2018, he had right shoulder arthroscopy with stabilization of the anterior superior capsulolabral repair. He was seen for a 2-month postoperative visit; on examination of the right shoulder the portal incisions were well-healed with no evidence of erythema, breakdown, or drainage present.  Passive range of motion with forward flexion was 170 degrees and with external rotation was 60 degrees.  The patient was to continue with formal postop rehabilitation per protocol and return to the office in four weeks.  
According to medical literature, an arthroscopic repair of the superior labrum anterior to posterior (SLAP) tear may be indicated when there is a SLAP tear visualized by arthroscopy, MRI or other imaging study.  Non-operative care has consisted of therapeutic interventions such as corticosteroid injection, nonsteroidal anti-inflammatories (NSAIDs) and physical therapy, and the patient has continued pain or limitations in range of motion.  

The physical examination findings revealed a shoulder joint injury and there was an MRI of the right shoulder that revealed a SLAP (superior labral tear from the anterior to the posterior) with anterior joint instability and non-acute Hill-Sachs deformity, which measures approximately 2.5 x 0.5 x 2.0 cm.  Therefore, the surgical services provided are considered medically necessary for this patient.  The insurer's denial is reversed.