Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right shoulder pain.
Treatment:  Complete Replacement of Shoulder Joint (23472).
The insurer denied the Complete Replacement of Shoulder Joint (23472).
The denial is upheld.

The patient is currently being treated weekly at the wound care center for a wound of his right chest wall.  Wound healing is complicated by the patient's inability to offload pressure due to decreased mobility.  The patient is wheelchair dependent and is unable to self transfer in his bed.  The nurse practitioner appeal states if the patient can obtain medical intervention to increase his functioning and independent transfer, would be of great benefit to the patient and increase his potential to heal his wound and prevent new wound from recurring.

The primary diagnosis is listed as Charcot's joint of right shoulder.  Right shoulder had been in pain for a few weeks with no specific injury.  Paraplegia from motor vehicle crash as a child with subsequent cyst development that caused paralysis.  Prior to this, the patient's right upper extremity was used for transfers and weightbearing.  He is unable to wheel himself in a wheelchair.  The note states he had recent cervical spine magnetic resonance image (MRI) with no evidence for syrinx.  Physical exam: the right or left shoulder is not documented.  It states massive effusion, pseudoparalysis shoulder with 20 degrees active/passive forward flexion.  Deltoid is described as functional; 2/5 strength.  Radiological studies: plain films and computed tomography (CT) were reviewed: no side is documented, left or right.   There is massive bony destruction and dislocation consistent with Charcot.  Treatment options were discussed with the patient.

Family practice follow up note states the patient was seen for bruising and swelling of the right shoulder.  There is no injury.  It states the right arm is limping and he has to use the left arm to move the right.  He notes that he leans on the right arm often and puts pressure on the right hand frequently for hours at a time while sitting in the wheelchair.  He has decreased sensation of the right side.  He has noticed bulging in the right shoulder intermittently for six months.  The patient had been having fevers for two weeks. The nurse practitioner states questioned possibility of septic joint given fevers.

Orthopedic follow up note: follow up for right shoulder pain.  No new information is presented in this note.

Computed topography (CT) of the right upper extremity: the radiologist's impression is nonspecific soft tissue findings around the right shoulder and a proximal humerus suggesting most likely inflammatory process of the neoplasm which does have a similar appearance.  There was no indication of acute osseous fracture.  Low-grade bone destructive process could have a similar appearance.

X-ray of the right shoulder: impression is anterior dislocation, deformity humeral head, very large effusion and the glenoid is not visualized.

Computed tomography (CT) of the right upper extremity: impression is very large clinic humeral joint effusion and bony deformity of the proximal humerus and glenoid is nonspecific, but septic joint would be on top of the differential and should be excluded.  New fracture at the right second rib.  Large fluid collection in the right axilla could be an abscess but this cannot be confirmed on the noncontrast exam.  Fluid tracts throughout the axilla and subadjacent to the pectoralis muscles and rotator cuff muscles cannot be evaluated possibly due to a combination of atrophy and phlegmon depending on clinical setting.

Emergency department note: the patient is a male with past medical history of paraplegia from the waist down with decreased sensation in the right side of his upper body, measurable prolapse, thrombocytopenia, and vitamin B12 deficiency.  He presents for evaluation of shoulder dislocation.  The clinic initially diagnosed a muscle tear and cellulitis approximately 2.5 weeks ago.  Clinic reports state he has been having fevers up to 101Fahrenheit.  Blood cell count was 7.22, and temperature was 97.3.  The patient was on oral antibiotics upon presentation to the emergency room (ER).  An aspiration was performed of the shoulder by the emergency department attending physician.

It is unclear based on the surgeon's notes, whether the planned procedure is a total shoulder arthroplasty or reverse shoulder arthroplasty. Based on the notes it may be a reverse shoulder arthroplasty as he discusses a computed tomography (CT) scan for a customized guide for glenoid baseplate.

No, the proposed treatment is not medically necessary.
The patient has been diagnosed with a neuropathic shoulder.  Shoulder replacement surgery in the setting of a neuropathic joint is contraindicated.  The attending physician's note states the "deltoid appears to be functional." Shoulder replacement surgery in the setting of an inactive deltoid is contraindicated.

Given the patient's neuropathic shoulder and possible inactive deltoid, the patient would be at extremely high risk for instability of the shoulder prosthesis, aseptic loosening, infection.

In the records provided there is concern about a septic shoulder joint and an aspiration was performed. In the records provided there is no documentation that a septic shoulder was ruled out. The results of the aspiration were not provided.

Per the Evicore Guidelines, total shoulder arthroplasty is considered not medically necessary for any other indication or condition including when any of the following criteria is present:
1) Active local or systemic infection
2) Paralytic disorder of the shoulder
3) One or more uncontrolled or unstable medical condition is that it significantly increased risk of morbidity
4) Charcot joint

The patient has a neuropathic shoulder.  Placing a shoulder prosthesis in a neuropathic joint is contraindicated in the current medical literature.