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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) referral to pain management and (2) referral for therapy for the hand/wrist. In this case, the patient is being treated for right hand pain, reporting throbbing pain even during sleep. An examination revealed full range of motion. X-rays reported no acute fracture or dislocation, chronic appearing well-corticated ossification adjacent to the ulnar styloid, suggesting sequela of prior trauma, and no significant degenerative changes. The patient reported that she frequently used the computer, and that the pain in her right hand and thumb became more persistent two months ago, and began waking her up every night about one month ago. She reported it was difficult to open a water bottle, and that writing with a pen felt like burning and needles. A physical examination reported tenderness to palpation at the base of the right thumb with a positive Finkelsteins test. Despite being requested, detailed documentation is not evident regarding the trial and failure of recent, reasonable, and comprehensive less invasive conservative care measures prior to referral. Given that a complaint of hand pain with negative x-rays would not, in itself, necessitate a referral to a specialist, the requested service is not medically indicated. Therefore, (1) referral to pain management is not medically necessary for the treatment of this patient.Medical literatures explain, De Quervain's tendinopathy affects the region of the wrist and the hand. Thumb motion becomes painful. This illness is caused by a degenerative process rather than inflammation. Primary treatment methods are splinting, taking non-steroid anti-inflammatory drugs and different physical therapeutic modalities, administration of a steroid injection into the tendon sheath or surgical release of the tendon sheath may be performed. The authors further noted that, With careful patient selection, conservative treatment complemented by eccentric training could be an alternative to current treatment options. Medical literatures also report that while data on the efficacy of treatment modalities in De Quervain's tenosynovitis is limited, adding paraffin therapy to the combination of the splint and therapeutic exercise positively affects treatment outcomes. Researchers report in a case study that conservative care of De Quervain's tenosynovitis involved anti-inflammatory medication and corticosteroid injections as well as occupational therapy to include splinting, activity modification, modalities, manual treatment, and therapeutic exercise. While the authors noted that the patient ultimately required surgery, conservative care was noted as assisting the patient with her symptoms initially. In this case, the patient presented to her provider with right hand pain. X-rays were normal. The patient reported persistent right hand pain. Given that current medical literature supports the use of physical therapy as the next step in conservative treatment for the noted pathology, the requested therapy for the hand/wrist is medically indicated. Therefore, (2) referral for therapy for the hand/wrist is medically necessary for the evaluation and treatment of this patient.Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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.