Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Arthroscopic shoulder surgery.

The insurer denied arthroscopic shoulder surgery.  The denial is partially overturned. 

The patient is a female with a complaint of bilateral shoulder pain. The records document that the patient underwent bilateral cortisone injections. Plain radiographs of each shoulder on that visit confirmed moderate bilateral acromioclavicular arthritis. A follow up examination was compared to prior date during which the patient complained of right shoulder pain greater than left. The patient was instructed on a home exercise program for both shoulders.  The patient was referred for a magnetic resonance imaging (MRI) scan of the right shoulder without contrast. This study was completed  and it confirmed an intact rotator cuff in the right shoulder as well as an intact glenoid labrum and biceps tendon. The study did confirm a type 2 acromion and arthritic changes in the acromioclavicluar joint. A final office visit was completed during which the physical examination of the right shoulder confirmed positive right shoulder impingement signs. The patient had described the symptoms for a duration of one year and her pain failed to improve after an injection of cortisone and physical therapy. The provider proposed right shoulder arthroscopic surgery for sub-acromial decompression and distal clavicle excision and a variety of other arthroscopic shoulder procedures.

The health plan's determination is partially overturned. 

The requested health service/treatment of arthroscopic shoulder surgery is medically necessary in part; specifically for acromioplasty and distal clavicle excision for this patient. The rationale for this determination is based upon the provided medical records, which document attempted conservative treatment for right shoulder impingement syndrome. The patient attempted oral medications, physical therapy and a cortisone injection which failed to relive her right shoulder pain. Her right shoulder MRI scan confirmed a type 2 acromion and signs of sub-acromial impingement. The requested right shoulder arthroscopic acromioplasty and distal clavicle excision is consistent with the recommendations of the current, peer-reviewed literature as documented by Jacobsen and colleagues in the Journal of Shoulder and Elbow Surgery in 2017. Thus, the acromioplasty and distal clavicle excision is medically necessary in this case.

The additional requests for rotator cuff repair, labral repair, capsulorrhaphy, synovectomy, debridement, and biceps tenodesis are not indicated based upon the pre-operative MRI scan, are not supported by the peer-reviewed literature, and are therefore not medically necessary.

The request for this patient included multiple CPT codes for this patient that were not indicated and not medically necessary. The booking sheet requested authorization for capsulorrhaphy (29806), labral repair (29807), partial and complete synovectomy (29820 and 29821), limited and extensive debridement (29822 and 29823), lysis of adhesions (29825), rotator cuff repair (29827). The pathology associated with these repair codes was not corroborated by the pre-operative MRI scan or the physical examination documented in the provided office notes. Therefore, the denial should be upheld pending a re-submittal of the appropriate CPT codes for this patient, who is a candidate for only right shoulder arthroscopic acromioplasty (29826) and distal clavicle excision (29824).