Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1: The patient is a 62-year-old male who primarily has a metatarsophalangeal joint (MPJ) Dupuytrens contracture. He has requested authorization and coverage for a needle aponeurotomy. The Health Plan has denied this request indicating that the efficacy of needle aponeurotomy has not yet been established.Needle aponeurotomy is a commonly used technique in France for the management of Dupuytrens contracture.  Currently, there are very few surgeons in the United States who use this approach to treat Dupuytrens disease. The technique involves inserting needles underneath the skin to divide the cord that is contracting the digit.  Because the procedure does not involve a skin incision, it is less morbid than a standard Dupuytrens release.  Open fasciectomy for the treatment of Dupuytrens disease results in healing that is often quite slow and, in severe cases, patients can be disabled for up to two months.  Needle aponeurotomy patients are generally able to return to normal functioning within 24 hours.  Thus, it appears morbidity is decreased with this technique.   Two criticisms have been leveled at this technique. The first is that nerve injury rates will be high because the nerve is not directly visualized when the cord is cut, and the second is that the recurrence rates are unacceptably high.  In a study of 211 consecutive patients undergoing this procedure, Fourcher et. al. found one nerve injury (out of 261 hands), no tendon injuries and no infections.  These rates compare favorably with the results of open fasciectomy. In contrast, a study by Bulstrode of 253 patients undergoing open fasciectomy identified 46 patients with complications (6 nerve injuries, 24 infections, 6 skin sloughs).  The recurrence rate in the needle aponeurotomy group was 58%, but many of these patients were treated with a second needle procedure. For the open group described by Bulstrode, the recurrence rate was 31%. Adam and Loynes, who found a 34% recurrence rate following fasciectomy, confirm the results of the Bulstrode study.  Although the recurrence rate is higher with the needle group, the recurrences can often be managed with a second needle procedure, whereas re-operating on a previously operated Dupuytrens hand is considerably more complex. Rowley et. al. describes the value of needle aponeurotomy particularly for patients with primarily MPJ contractures.  This patient has a 90-degree MPJ contracture and a 20-degree proximal interphalangeal joint (PIPJ) contracture. He is likely to derive significant benefit from a needle aponeurotomy with a low complication rate. Furthermore, if he should develop a recurrence, it should be relatively easy to manage with a second aponeurotomy procedure.  In summary, I have determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 2: The patient is a 62-year-old male with a well-established diagnosis of Dupuytrens contracture. His condition is now at a stage that requires surgery or other invasive management. The patient believes needle aponeurotomy is the most appropriate technique for treatment of his condition. The Health Plan indicates the efficacy of needle aponeurotomy remains unproven at this time.There are no studies in the United States literature indicating or even suggesting that needle aponeurotomy is superior to palmar/digital fasciectomy. Some abstracts in the French literature suggest that the results may be comparable to fasciectomy but controlled studies have not been performed in the United States. To date, fasciectomy, remains standard of care for Dupuytrens contracture with proven efficacy in cases such as this case. Accordingly, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3: The patient is a 62-year-old male with Dupytrens contracture of the left small finger. The patients provider has determined the patient to be an appropriate surgical candidate. The patient is concerned that surgery will require a lengthy recovery period. The patient feels a needle aponeurotomy is more appropriate in his case. The Health Plan has denied coverage for the requested procedure on the basis that it is considered experimental/investigational.Indications for partial palmar fasciectomy are valid in this case. As of yet, there is inadequate outcome data in the literature demonstrating that needle aponeurotomy provides better outcomes, fewer complications or an earlier return of function. The patient can be appropriately treated with palmar fasciectomy. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.