Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
The patient is a 53-year-old female. Magnetic resonance imaging (MRI) of the left shoulder dated 
10/18/22 reported the following findings: moderate osteoarthritis changes at the glenohumeral 
joint; small shoulder joint effusion; ill-defined intermediate proton density/T2 signal in the axillary 
recess of the shoulder joint compatible with intra-articular debris versus synovitis; several sub-
centimeter  hypointense  loose  bodies  in  the  subscapularis  recess;  mild  tendinosis  of  the 
supraspinatus tendon on both superimposed small low-grade interstitial tears in the distal tendon 
and bursal surface fraying of the tendon; mild tendinosis of the infraspinatus tendon although the 
infraspinatus tendon is intact; degenerative tears in the superior, posterior-superior, anterior-
superior, and anterior-inferior labrum; mild tendinosis of the long head biceps tendon; minimal 
degenerative change at the acromioclavicular joint; and mild posterior subluxation of the humeral 
head relative to the glenoid, although no bone contusion, fracture, or dislocation was identified. 
The patient has requested authorization and coverage for arthroplasty, glenohumeral joint; total 
shoulder [glenoid and proximal humeral replacement (example: total shoulder)]; left. The Health 
Insurer has denied this request and reported that the requested service is not medically necessary 
for the treatment of this patient. This denial is the subject of this appeal and determination. The 
physician reviewer found that the submitted documentation supports the medical necessity of the 
requested service. In a review of shoulder replacement for osteoarthritis, Pandya and colleagues 
report, Initial treatment should be non-operative, such as activity modification, oral analgesics 
(for example, nonsteroidal anti-inflammatories) and possibly physical therapy or corticosteroid 
injections. Patients with ongoing severe pain and functional restriction despite non-operative 
treatment would be candidates for surgery, usually a shoulder replacement. The most common 
indication for total shoulder arthroplasty is osteoarthritis. In a systematic literature review and 
meta-analysis of the impact of total shoulder arthroplasty in generic and shoulder-specific health-
related quality-of-life measures, Carter and colleagues conclude, Total shoulder arthroplasty 
leads to significant improvements in scores for function and pain. Shoulder-specific measures of 
function consistently showed the greatest degree of improvement, with large effect sizes. Total 
shoulder arthroplasty also leads to significant improvements in overall physical well-being, with a 
moderate-to-large effect size. In this case, the patient has a history of right total shoulder 
arthroplasty and arthritis of the left shoulder. An examination of the left shoulder revealed a range 
of motion of 150/85/30/L5, with strength noted as 5/5 with pain. The patient had tried and failed 
medications and injections for the left shoulder, including PRP injections. An undated letter from 
the patients physical therapist reported that physical therapy is not indicated for the left shoulder 
prior  to  surgery.  An  MRI  dated  10/18/22  showed  moderate  osteoarthritis  changes  at  the 
glenohumeral joint. In this case, given that the records demonstrate subjective and objective 
deficits that are corroborated by imaging studies along with the trial and failure of conservative 
treatment modalities, and as current medical literature supports the requested service as safe and 
effective, the requested service is medically indicated. Therefore, arthroplasty, glenohumeral joint; 
total shoulder [glenoid and proximal humeral replacement (example: total shoulder)]; left is 
medically necessary for the treatment of this patient.