Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a superior capsular reconstruction procedure. 
 
You asked the Plan to pre-approve a superior capsular reconstruction procedure. You say that the requested 
superior capsular reconstruction procedure is medically necessary. The Plan denied your request. The Plan says 
that the requested superior capsular reconstruction procedure is 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 a superior capsular reconstruction 
procedure. Our reviewer says that the requested superior capsular reconstruction procedure is medically 
necessary. Our physician reviewer found this enrollee presents with complaints of worsening left shoulder pain, 
weakness, and loss of range of motion. Significant functional limitations are noted in activities of daily living 
and pain disrupts her sleep. Clinical exam findings have documented flexion and abduction limited to 90 
degrees, and significant rotator cuff weakness. There is imaging evidence of massive rotator cuff tear involving 
the supraspinatus and infraspinatus tendons with retraction to the level of the glenohumeral joint. There is 
rotator cuff muscle atrophy and no evidence of significant shoulder joint arthritis. She has failed reasonable 
and/or comprehensive conservative treatment. Under consideration is a request for left shoulder superior 
capsular reconstruction. The orthopedist has reported the enrollee had clinical signs of pseudoparalysis as well 
as left shoulder weakness and pain due to superior migration of the humeral head and instability. He has 
recommended this procedure as an alternative to reverse total shoulder arthroplasty given the absence of 
arthritis on MRI. Current evidence based medical literature has shown superior capsular reconstruction to be a 
useful treatment modality for patients with irreparable rotator cuff tears. In the setting of no glenohumeral 
arthritis and to avoid reverse total shoulder arthroplasty, the use of superior capsule reconstruction as a relative 
salvage procedure is reasonably indicated. Therefore, this request for superior capsule reconstruction 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 a superior capsular reconstruction procedure have been met. Therefore, we 
decided that the Plan has to pre-approve a superior capsular reconstruction procedure.  
 
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.