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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for electromyography (EMG) of the left shoulder blade muscles (supraspinatus plus infraspinatus muscles), nerve conduction study (NCS) of the left shoulder blade muscles (supraspinatus plus infraspinatus muscles), ultrasound of the left shoulder, and magnetic resonance imaging (MRI) with contrast of the left knee for evaluation of his chronic pain and numbness. Findings:  The physician reviewer found that the requested EMG and NCS of the left supraspinatus and infraspinatus muscles are not medically necessary for evaluation of this patients medical condition. The patient does not have consistent physical findings of suprascapular neuropathy such as weakness of external rotation of the humerus due to infraspinatus weakness, which is the major clinical manifestation of a suprascapular nerve lesion. Most recent documentation reveals no shoulder atrophy or winging. There are no signs of scapular winging as seen in lesions of the dorsal scapular nerve. The left arm external rotation in recent documentation is only slightly limited and is 20 degrees greater than the right side. In addition, the documentation reveals that NCS are limited in damage to the dorsal scapular nerve. Further, the literature states that with evaluating for both suprascapular neuropathy and dorsal scapular neuropathy needle EMG should not be limited to these muscles as a diffuse process such as a cervical radiculopathy may not be confirmed. The patients symptoms suggest cervical/radicular pathology, therefore a limited needle EMG would not be conclusive if there are findings in the supraspinatus and infraspinatus on testing of only these muscles. An ultrasound of the left shoulder is not medically necessary as the literature on suprascapular neuropathy reveals that a MRI of the shoulder is the best way to visualize the degree of supraspinatus and infraspinatus atrophy, to look for soft tissue masses around the shoulder, to assess for labral and rotator cuff pathology, and to examine the course of the nerve itself through the bony prominences. Furthermore, the current guidelines reveal that ultrasound is typically done for localized pain and this patient has diffuse symptoms. The patient already had been evaluated with a left shoulder MRI and x-ray and there was no evidence on these studies that would indicate an additional ultrasound of the left shoulder. With regard to the requested MRI of the left knee, the patient already had an MRI of the left knee and he refused surgical intervention for his meniscal tear and ACL irregularities. Moreover, there are no red flag findings that would require an additional MRI scan with contrast. It is unclear how an additional left knee MRI would change the medical management of this patient. Accordingly, the requested MRI with contrast of the left knee is not medically necessary for evaluation of this patients left knee pain. Final Result: The reviewer determined that the requested diagnostic procedures are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine 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.