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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for left shoulder surgery (arthroscopy - CPT 29826). Findings:  The physician reviewer found that 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. In this case, the patient is being treated for a left shoulder partial rotator cuff tear. The patient reported pain in her left shoulder that had responded to a cortisone injection but had now recurred. She was working with an athletic trainer but reported that exercises for the upper extremities were difficult due to her left shoulder pain. An examination revealed left shoulder active assisted forward elevation of 160, abduction of 160, with external rotation of 50 when the arm was at the side, and internal rotation to L4. A drop-arm test was intact with pain. Impingement signs were noted as 1 and 2+2. The patient had good strength with internal resistance and mild weakness with external rotation. X-rays of the left shoulder showed a normal glenohumeral joint, moderate acromioclavicular joint arthropathy, irregularity, and osteophyte greater tuberosity. The provider noted left shoulder partial rotator cuff tear and ordered magnetic resonance imaging (MRI) of the left shoulder to evaluate for possible regression of rotator cuff tear. The records noted acromioclavicular joint osteoarthritis with mild undersurface hypertrophy, minimal fluid at the acromioclavicular joint, and coracoclavicular ligament that appeared intact. The degree of pathology denoted in these findings does not support the addition of acromioplasty to rotator cuff repair. Given the lack of evidence in current medical literature supporting significant clinical outcome improvements with addition of an acromioplasty or of distal clavicle resection in combination with a rotator cuff repair, the requested service is not medically indicated. Therefore, left shoulder surgery (arthroscopy - 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.