Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Numbness and tingling in arm
Treatment: Elective inpatient admission for procedure to remove your first rib.
The insurer denied Elective inpatient admission for procedure to remove your first rib.
The determination is upheld.

This is a female patient who presented for evaluation of her right arm pain. She has a distant history of smoking. She has a distant motor vehicle collision (MVC) causing whiplash. The patient states that the pain in her right arm was initially described as pleuritic pain in her armpit but moved up to her shoulder and this started shortly after her child was born. This was initially treated as a pulled muscle and she was eventually started with physical therapy. The pain in her neck and shoulder as well as the numbness and tingling in her right arm did not improve with physical therapy and has continued to progress.  She has symmetrical pulses and a negative Adson/Overhead positioning test. She has undergone electromyography (EMG) testing which were non-diagnostic. Imaging studies were not referenced or reviewed. 
At issue is the medical necessity of elective inpatient admission for procedure to remove your first rib.

At the current time, the health service is not medically necessary.
The patient has neurological symptoms of unknown etiology at this point.  The differential diagnosis includes thoracic outlet syndrome but the presence of a cervical rib or bony spurs is not demonstrated.  In addition, in the setting of non-diagnostic electromyography (EMG), additional imaging and a possible neurologic evaluation is advisable.   There is no thoracic or cord imaging referenced or included in the records provided.  These tests would be advisable to evaluate for thoracic outlet syndrome and other etiology of the patient's symptoms before proceeding with surgery. 
As evaluated with the current records, the procedure cannot be determined to be medically necessary. The evaluation should be fully performed and reassessed. It appears that the patient has thoracic outlet syndrome and may benefit from first rib resection. However, the imaging studies and anterior scalene block need to be assessed and were not provided for review. The criteria that need to be met are:
Nonspecific ("disputed") neurogenic thoracic outlet syndrome (ie (that is), symptoms without electrodiagnostic abnormalities or vascular impairment), as indicated by all of the following
-	Evaluation for other causes of upper extremity pain (eg (for example), diabetic neuropathy, vasculitis, distal nerve compression, cervical disk disease) negative
-	No planned return to employment involving repetitive motion
-	Positive response to diagnostic anterior scalene muscle block
-	Symptoms have not responded to nonsurgical management, including 1 or more of the following:
-	Adhesive elastic bandages
-	Bracing to elevate or retract shoulder girdle
-	Medication (eg, nonsteroidal anti-inflammatory drugs (NSAIDs))
-	Physical therapy for 8 or more weeks
-	Strengthening exercises
-	Taping
Imaging reports of the chest are needed. Computed tomography (CT) / magnetic resonance imaging (MRI) reports were requested but not received. Therefore, the procedure cannot be determined to be medically necessary based on the information provided.