Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Shoulder Pain
Treatment: Surgery (shoulder arthroplasty) and Inpatient Hospital Admission The
insurer denied the Surgery (shoulder arthroplasty) and Inpatient Hospital
Admission.
The denial is overturned.

The patient is a female who presented with chronic right shoulder pain. She was
diagnosed with recurrent dislocations with increasing pain over the past four years.
She had received treatments of physical therapy (PT) and cortisone injection which did not provide lasting pain relief. She reported difficulty with activities of daily living, use of arm and night pain.

The patient's past medical history (PMH) was significant for obstructive sleep apnea
(OSA) on continuous positive airway pressure (CPAP), coronary artery disease
(CAD), morbid obesity with body mass index (BMI) greater than (>) 35. (Other
records showed body mass index [BMI] 28.57, no evidence of obstructive sleep
apnea [OSA] on continuous positive airway pressure [CPAP].)

The patient's physical examination noted decreased motion, crepitus, weakness,
and positive (+) Obrien test. A computed tomography (CT) report showed end
stage bone on bone arthritis. Her physician recommended a total shoulder
replacement (TSR). The patient underwent right total shoulder replacement (TSR
R). A drain was placed. She required ongoing medications for pain control. Her
drain was removed and physical therapy (PT) was provided. She was then
discharged.

Yes, the proposed Surgery (shoulder arthroplasty) and Inpatient Hospital Admission
was medically necessary.

The medical record was consistent for the diagnosis and treatment provided. The
patient was found to have chronic pain, limitations to activities, positive findings on
physical examination and correlative imaging. She has end stage post traumatic
arthritis secondary to recurrent dislocation. A pain generator had been defined. The
next step would be operative intervention as provided.

Using Clinical AIM Clinical Guidelines for Shoulder Arthroplasty:

Advanced joint disease of the shoulder due to osteoarthritis, rheumatoid arthritis,
avascular necrosis, or post-traumatic arthritis when ALL of the following
requirements are met:

Limited range of motion or crepitus of the glenohumeral joint on physical
examination, (MET. The records showed decrease motion in all planes and crepitus.)

Pain and loss of function of at least six months' duration that interferes with daily
activities, (MET. The patient had difficulty with activities and night pain.)

Radiographic evidence of destructive degenerative joint disease as evidenced by
two or more of the following:

Irregular joint surfaces
Glenoid sclerosis
Osteophyte changes
Flattened glenoid
Cystic changes in the humeral head
Joint space narrowing,
(MET. The physician reported end stage disease with bone on bone. This would
include all of the above.)

Failure of conservative management of at least six weeks' duration,
(MET. The records showed recent cortisone injection and courses of physical
therapy [PT]).

Surgery would thus be appropriate.

The inpatient stay was also necessary based upon the complexity and extent of
surgery being performed. The duration of the operation would likely be several
hours. There would be associated blood loss. Pain would be expected to be severe.
For these reasons, inpatient admission would be appropriate and necessary.

The clinical records substantiate necessity of surgery.