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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a short-stem resurfacing procedure for the right shoulder.Researchers indicate that the potential advantages of humeral resurfacing, as compared with conventional shoulder arthroplasty, are: (1) no osteotomy is performed (and thus the head-shaft angle does not have to be addressed); (2) minimal bone resection; (3) a short operative time; (4) a low prevalence of humeral periprosthetic fractures; and (5) ease of revision to a conventional total shoulder replacement, if needed. Outcomes of surface replacement arthroplasty have been comparable with those of arthroplasties with a stemmed prosthesis in numerous short and mid-term follow-up studies. Future studies are required to assess the long-term outcomes of humeral resurfacing and to evaluate alternative surface bearing materials, especially on the glenoid side. Resurfacing appears to be a viable option for shoulder replacement, especially in young patients. Medical literature concluded that the indications for glenoid resurfacing are controversial. Advantages of glenoid resurfacing include decreased glenoid pain from metal-on-bone articulation, increased stability provided by the conforming glenoid component in the presence of asymmetric glenoid wear, and lateralization of the joint line providing for improved range of motion and strength. Patients with severe rotator cuff disease, persistent instability, and lack of glenoid bone stock should be treated with hemiarthroplasty alone because glenoid resurfacing is associated with early loosening and failure.In this case, the patient presents with complaints of bilateral shoulder pain, right greater than left, and decreased range of motion. The patients functional limitations are noted in activities of daily living. Her clinical exam findings are reported consistent with imaging evidence of severe glenohumeral osteoarthritis with effusion, moderate tendinopathy of the long head of the biceps tendon, moderate-severe acromioclavicular joint arthrosis, and rotator cuff tendinopathy with at least partial-thickness tearing of the supraspinatus. There is radiographic evidence of bone-on-bone glenohumeral osteoarthritis. The patient has requested authorization for a resurfacing procedure of the right shoulder. Current evidence based medical literature indicates that resurfacing appeared to be a viable option for shoulder replacement, especially in younger patients. Glenoid resurfacing is associated with early loosening and failure in patients with severe rotator cuff disease, persistent instability, and lack of glenoid bone stock. In this case, there is no consensus between the physicians on the surgical treatment plan. However, the active patients age, deficient rotator cuff, shoulder osteoarthritis, knowledge and positive experience with resurfacing supports the requested procedure. The short stem resurfacing procedure represents a reasonable alternative to ongoing non-operative and more invasive shoulder replacement. Therefore, a short-stem resurfacing procedure for the right shoulder is medically necessary for treatment of the patients medical condition (right shoulder osteoarthritis and tears in the rotator cuff).Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patient's medical condition. Therefore, the Health Plans denial should be overturned.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.