Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve the shoulder repair surgery (tenodesis of long tendon of biceps, 
arthroscopy, shoulder, surgical; debridement, extensive, arthroscopy, shoulder, surgical, distal claviculectomy 
including distal articular surface, arthroscopy, shoulder, surgical; with lysis and resection of adhesions, with or 
without manipulation, arthroscopy, shoulder, surgical; decompression of subacromial space with partial 
acromioplasty, with or without coracoacromial release, arthroscopy, shoulder, surgical; with rotator cuff repair, 
and arthroscopy, shoulder, surgical; biceps tenodesis). 
 
You asked the Plan to pre-approve the services. You say that the surgery is necessary. The Plan denied your 
request. The Plan says that the surgery is not medically necessary. 
 
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 services. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found this enrollee presents with complaints of severe right shoulder pain. Pain increases with lifting 
and movement. Clinical exam findings are generally consistent with imaging findings reported by the 
orthopedic surgeon to include tendinosis of the superior aspect of the subscapularis, full thickness tear of the 
leading edge of the supraspinatus, and possible partial-thickness biceps tendon tear. There is imaging evidence 
of AC joint degenerative change. The orthopedic surgeon reports that the enrollee has not received any 
conservative treatment. The enrollee wishes to proceed with surgery. Under consideration is a request for right 
shoulder arthroscopic surgery with CPT codes 23430, 29823, 29824, 29825, 29826, 29827, and 29828. At this 
distant point in time post injury, it is improbable that any combination of physical therapy and medications 
would reasonably resolve the shoulder pain magnitude and motion deficit. In fact, such attempts could result in 
increased painful morbidity, greater tearing of the soft tissues and aggravated AC arthritis. The individual is 
markedly adversely affected with activities due to the documented shoulder pathology. In addition, a similar 
surgical procedure on the enrollee's opposite shoulder appears to have resulted in a positive outcome. 
Therefore, this request for right shoulder surgery (CPT codes 23430, 29823, 29824, 29825, 29826, 29827, and 
29828) is considered medically reasonable and necessary as a medically indicated relative exception to criteria. 
 
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 services have been met. Therefore, we decided that the Plan has to pre-
approve the shoulder repair surgery (tenodesis of long tendon of biceps, arthroscopy, shoulder, surgical; 
debridement, extensive, arthroscopy, shoulder, surgical, distal claviculectomy including distal articular surface, 
arthroscopy, shoulder, surgical; with lysis and resection of adhesions, with or without manipulation, 
arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with or 
without coracoacromial release, arthroscopy, shoulder, surgical; with rotator cuff repair, and arthroscopy, 
shoulder, surgical; biceps tenodesis).