Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1: The patient is a 51-year-old man who sustained a right shoulder fracture from a fall off a six-foot ladder. Two months following the injury, x-rays demonstrated the shoulder has failed to heal properly. The patients physician has recommended the patient use the Dynasplint shoulder system. The Health Plan has denied coverage for the requested equipment on the basis it is considered investigational for treatment of the patients condition. The requested equipment has been used for years to treat joint immobility. The treatment of adhesive capsulitis includes medication, injections, and physical therapy. The Dynasplint will help with home therapy; failure to improve will necessitate surgery. The requested equipment is medically reasonable and the results are likely to be superior to those associated with any other therapy. As such, I have determined that the requested equipment is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned. Physician 2: The patient is a 51-year-old man who sustained a right proximal metaphyseal humerus fracture after a fall from a ladder. He has undergone strengthening and stretching exercises and physical therapy. In November 2004, x-rays revealed post injury adhesive capsulitis. The patients physician has recommended the patient receive a Dynasplint shoulder system to assist in the healing of the fractured shoulder. The Health Plan has denied this request indicating the efficacy of the requested equipment has not been proven in peer-reviewed literature. The patient has a frozen shoulder post fracture. Review of the medical literature reveals no evidence the Dynasplint shoulder system will be more effective than standard therapy for treatment of this patients condition. The patient is likely to respond over time to heat and physical therapy for stretching. In the event the patients condition fails to respond to standard therapy within six months, surgical release may be warranted. In any event, there is insufficient data to support the use of the requested equipment in this clinical setting. Based upon the information set forth above, I have determined that the requested equipment is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld. Physician 3: The patient is a 51-year-old male who sustained a comminuted right proximal humeral metaphyseal fracture on 9/8/04. His fracture was managed non-operatively by the treating physician who followed him at regular intervals over a period of 4.5 months. At various points during the course of his follow-up, there appeared to be concerns regarding the completeness of fracture healing. Based upon x-rays obtained in January 2005, the treating physician felt there was advanced healing of the proximal humeral fracture. The patients residual disability was felt to be predominantly related to post-traumatic adhesive capsulitis. The patients provider has requested a Dynasplint shoulder system to help facilitate restoration of shoulder range of motion. The Health Plan has denied coverage for the requested equipment. A review of the orthopedic literature including the Journal of Bone and Joint Surgery, the Journal of American Academy of Orthopaedic Surgeons, and the Instructional Course Lectures of the American Academy of Orthopaedic Surgeons failed to reveal any articles substantiating the benefit of a dynamic device such as the Dynasplint shoulder system for treatment of adhesive capsulitis of the shoulder. There is some suggestion that such devices may be effective if used early (i.e., within 6-8 weeks of injury or surgery) in the treatment of post-traumatic contractures of hinged type joints such as the knee or elbow. No such evidence exists in the case of post-traumatic adhesive capsulitis of the shoulder. In this patients case, a Dynasplint shoulder system is unlikely to be more beneficial than any available and traditional methods of therapy for post-traumatic adhesive capsulitis. Therefore, I have determined that the requested equipment is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.