Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve rotator cuff repair with capsulorrhaphy, superior capsule reconstruction and dermal allografting.
You asked the Plan to pre-approve the requested surgical procedure. You say that the enrollee's injury is very likely to be irreparable and the use of a superior capsule reconstruction may be the only way to improve pain and level of function. The Plan denied your request. The Plan says that there is insufficient data regarding the safety and efficacy of this procedure. It should be considered experimental.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested surgical procedure. Our reviewer says that the requested services are considered medically reasonable and necessary for this particular enrollee's condition. Our physician reviewer found et al concluded that superior capsule reconstruction (SCR) is a useful treatment modality for patients with irreparable rotator cuff tears. SCR was associated with significantly improved functional outcome scores in all studies. The radiological graft failure rate ranged from 4.2 to 55% and the short duration of follow-up in most studies means that this remains an important concern that requires longer-term evaluation. This enrollee presents with a chronic full thickness retracted right shoulder rotator cuff tear. She reports worsening right shoulder pain and weakness. Clinical exam findings are consistent with imaging evidence of a full thickness supraspinatus rotator cuff tear retracted to the level of the AC joint. There is no evidence of glenohumeral joint arthritis. She has failed long-term reasonable and/or comprehensive conservative treatment. Under consideration is a request for right shoulder superior capsular reconstruction. The orthopedist has opined that the rotator cuff might not be fully repairable and the superior capsular reconstruction procedure was required to improve her function and pain, prevent progressive rotator cuff arthropathy, and avoid reverse total shoulder arthroplasty. Current evidence based medical literature has shown superior capsular reconstruction to be a useful treatment modality for patients with irreparable rotator cuff tears. In the setting of no glenohumeral arthritis and to avoid reverse total shoulder arthroplasty, the use of superior capsule reconstruction as a relative salvage procedure is reasonably indicated. Therefore, this request for rotator cuff repair with superior capsule reconstruction and dermal allograft is medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested surgical procedure have been met. Therefore, we decided that the Plan has to pre-approve rotator cuff repair with capsulorrhaphy, superior capsule reconstruction and dermal allografting.