Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Rotator cuff tear.
Treatment: Arthroscopy, Shoulder, Surgical: (procedure codes 29827, 29828, 29826) Rotator Cuff Surgery.

The insurer denied Arthroscopy, Shoulder, Surgical: (procedure codes 29827, 29828, 29826) Rotator Cuff Surgery.  The denial is overturned.

The patient is a male who was diagnosed with an incomplete right shoulder rotator cuff tear. This is a request for Arthroscopy, Shoulder, Surgical: Rotator Cuff Surgery. There is an operative report stating that a right shoulder arthroscopy with rotator cuff repair, biceps tenodesis, and subacromial decompression was performed. The request was previously denied by the plan based on lack of medical necessity.

A right shoulder magnetic resonance imaging (MRI) was consistent with biceps subluxation and a partial rotator cuff tear. A clinical note documents an office visit. The treatment included physical therapy and non-steroidal anti-inflammatory drugs (NSAIDs). There is a clinical note documenting a visit with an orthopedic surgeon. The initial injury involved a fall on the porch. The patient has a pain rating of 7-8/10, numbness, and shooting pain. The treatment has included activity modifications. The comorbidities include hypertension. Objectively, there was active 140, abduction 140, external rotation 50, 5 negative (-)/5 strength upon supraspinatus testing, and 4/5 strength upon internal and external rotation. There is tenderness over the greater tuberosity, acromioclavicular joint, sternoclavicular joint, clavicle, spinous scapula, and bicipital groove. There was a positive O'Brien test, Jobe's test, and pain with resisted biceps testing. The treatment plan included surgery. The subject under review is the medical necessity for the requested shoulder surgery.

The health plan's determination is overturned.

The requested arthroscopy, shoulder, surgical: rotator cuff surgery was medically necessary, appropriate, and in the best interest of this patient.

The article cited below from the Journal of the American Academy of orthopedic surgeons states that surgical intervention for partial thickness rotator cuff tears should be considered after failure to 3-6 months of conservative management and for younger patients with acute traumatic injuries. The article cited below from the arthroscopy Journal states that the group of patients with rotator cuff tears surgically treated with concomitant biceps tenodesis or tenotomy had 94% resolution of subpectoral tenderness. The article cited from the orthopedic surgery Journal states that the biceps is effective for concomitant lesions of the 10 and in in those with repairable rotator cuff tears.

In this case, the patient has a diagnosis of biceps subluxation and a partial rotator cuff tear. There had been treatment with therapeutic exercise, activity modification, and NSAIDs. The conservative treatment was at least initiated and surgical intervention was performed. While the specific duration of each conservative treatment is not specified, the documentation does indicate that there was considerable pain, restricted motion, weakness, positive Speeds, O'Briens, and Jobe's tests. In this scenario, proceeding with surgical intervention was appropriate and further nonoperative management could have resulted in progression of the derangement and need for more invasive surgery. Based on the available information, arthroscopy, shoulder, surgical: rotator cuff surgery was medically necessary for this patient.