Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with a left ring finger proximal interphalangeal (PIP) joint flexion contracture. Physical examination findings included mild swelling of the left ring finger. Left ring finger PIP joint range of motion was to 45 degrees in extension. The collateral ligaments were stable to stress testing, and the patient denied experiencing pain on stress testing. There was reasonable strength and intact sensation. In a letter, the provider noted the patient sustained trauma to his left ring finger. The patient has been treated with hand therapy with dynamic splinting and range of motion exercises. The provider noted that the patient developed a flexion contracture of the PIP joint, which was static. The patient has requested authorization and coverage for a Dynasplint Proximal Interphalangeal Extension System (HCPCS E1825) for the left ring finger. The Health Plan denied the request and reported that the requested device is not medically necessary for the treatment of this patient. At issue in this case is whether a Dynasplint Proximal Interphalangeal Extension System (HCPCS E1825) for the left ring finger is medically necessary for the treatment of the patients medical condition. Researchers noted that, Proximal interphalangeal joint (PIPJ) flexion contracture is a challenging and often frustrating problem. Treatment of PIPJ contracture begins with conservative measures. With good compliance and prolonged use, favorable results can be achieved using these modalities. For contractures that fail to respond to conservative treatment, surgical intervention can be considered. Tocco and colleagues reported, PIPJ flexion contractures are a common clinical problem seen by hand therapists and orthopedic surgeons after various types of injury to the finger. Conservative treatment management was preferable over surgery but a variety of pre-fabricated and custom-made orthoses have been proposed in the literature. Synthetic serial casting and static-progressive splinting were opined as the best choices to treat even the most resilient PIPJ flexion contractures as they both offer maximal Total-End-Range-Time (TERT) and minimize functional impediment of the hand while they are in use. A study reported, Static progressive and dynamic splints are considered effective non-operative interventions to treat stiff fingers. Current evidence-based medical literature generally supports the use of static progressive splinting for PIP joint flexion contractures. In this case, the patient has had a prior trial of hand therapy and compliance with a home program, including range of motion exercises. Exceptional indications are evident to support the medical necessity of Dynasplint, at this time. The medical evidence supports the requested device in this clinical setting. Therefore, a Dynasplint Proximal Interphalangeal Extension System (HCPCS E1825) for the left ring finger is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested device is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.