Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Orthopedic/Musculoskeletal. 
Treatment:  Shoulder surgery (arthroscopy).  

The insurer denied shoulder surgery (arthroscopy).  The denial is upheld in whole.

The patient is a male with a complaint of left shoulder pain.  Pre-operative x-rays confirmed shoulder impingement with some glenohumeral joint changes and acromioclavicular joint arthritis.  The patient underwent left shoulder arthroscopic surgery.  The shoulder surgery included an arthroscopic sub-acromial decompression, glenohumeral debridement and biceps tenodesis.  The medical necessity of the left shoulder arthroscopic biceps tenodesis (CPT 29828) was denied as not medically necessary.  At issue in this case is the medical necessity of the left shoulder arthroscopic biceps tenodesis that was performed.

The requested health service/treatment of arthroscopic biceps tenodesis was not medically necessary for this patient.  The rationale for this determination is based upon the provided medical records and the recommendations of the current, peer-reviewed orthopedic literature.

The provided medical records included the operative note dictation.  This detailed the surgery.  The operative note states that the patient had significant fraying of the biceps tendon.  The were no pre-operative office notes provided in this case.  Thus, there was no documentation of pain in the biceps region.  There was no documentation of tenderness in the bicipital groove or positive provocative testing of the biceps tendon on physical examination of the patient.  There was no documentation in the note of a partial tear of the biceps or how much damage was present in the intra-articular portion of the biceps to justify the performance of an arthroscopic biceps tenodesis.  In addition, there was no pre-operative magnetic resonance imaging (MRI) scan of the left shoulder performed documenting radiographic evidence of the damage to the biceps tendon prior to surgery, and there was no pre-operative physical examination documenting provocative physical exam testing of the biceps tendon.  Therefore, the medical necessity of the arthroscopic biceps tenodesis is not established based on the provided medical records.

The current, peer-reviewed orthopedic literature contains multiple studies that provide guidance and evidence based criteria for the management of biceps tendon pathology.  A recent study published by Lee and colleagues in the Journal of Shoulder and Elbow Surgery concluded, "For the treatment of long head of the biceps tendon lesions with rotator cuff tear, patients with tenotomy and tenodesis both showed significant improvements in functional scores."  This was a prospective, randomized study that enrolled 128 patients undergoing arthroscopic shoulder surgery.  A second study published by Patel and associates also documented the benefits and clinical outcome of biceps tenodesis and tenotomy surgery.  In reference to this case, the provided records do not document the provider's decision to perform biceps tenodesis rather than biceps tenotomy in this patient with underlying shoulder degenerative changes and an intact rotator cuff.  The provided medical records fail to document the medical necessity of the procedure performed.  In addition, the current, peer-reviewed orthopedic literature contains evidence-based criteria for the performance of arthroscopic biceps tenodesis, which are not met in this case.