Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve open treatment of articular fracture, involving 
metacarpophalangeal or interphalangeal joint, includes internal fixation, when performed, treatment of 
dislocation and arthrodesis, interphalangeal joint, with or without internal fixation. 
 
You asked the Plan to pre-approve the requested surgical procedures for the finger joints. You say that you 
have been dealing with pain and loss of function due to your condition. You feel that surgery is the only choice 
to help at this time. The Plan denied your request. The Plan says there has not been sufficient conservative 
treatment to suggest that surgery is required at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 requested surgical procedures for 
the finger joints. Our reviewer says that the requested surgical services are not considered medically reasonable and necessary in this case. Our physician reviewer found this 73-year-old female was being treated for 
Heberdens Nodes with arthropathy. She presented with hand pain located at the DIP (distal interphalangeal) 
joints of all of her digits. Exam reveals diffuse Heberdens nodes noted. There is tenderness to palpation in the 
DIP joints of all of her fingers. X-rays of the bilateral hands were noted to show no acute fractures or 
dislocations; diffuse arthritis throughout the DIP joints of hands. 
 
However, detailed documentation is not evident regarding trial and failure of recent, reasonable, and 
comprehensive less invasive conservative care measures. She is noted to be taking medications. However, no 
physical/occupational therapy has been trialed, and documentation does not indicate injection therapy has been 
tried and failed. Additionally, there is limited published, large-scale, long-term peer-reviewed literature that 
shows this request to be an effective and/or safe treatment for the noted pathology. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the requested open treatment of articular fracture, involving metacarpophalangeal or 
interphalangeal joint, includes internal fixation, when performed, treatment of dislocation and arthrodesis, 
interphalangeal joint, with or without internal fixation, in this case, is not medically reasonable or necessary.  
 
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 requested surgical procedures for the finger joints have not been met. 
Therefore, we decided that the Plan does not have to pre-approve open treatment of articular fracture, involving 
metacarpophalangeal or interphalangeal joint, includes internal fixation, when performed, treatment of 
dislocation and arthrodesis, interphalangeal joint, with or without internal fixation.