Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fixation of shoulder (23700). 
 
You asked the Plan to pre-approve fixation of shoulder (23700). You say that the requested fixation of shoulder 
(23700) is medically necessary. The Plan denied your request. The Plan says the requested fixation of shoulder 
(23700) is not medically necessary. 
 
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 fixation of shoulder (23700). Our 
reviewer says that the requested fixation of shoulder (23700) is not medically necessary. Our physician 
reviewer found the enrollee was being treated for adhesive capsulitis of the right and left shoulder. She 
presented noting that her discomfort has improved substantially with physical therapy. She continues to be 
functionally compromised. The current pain level is 5. The exam of the right shoulder reveals active and 
passive range of motion exhibits glenohumeral ankylosis with forward flexion to 80, abduction 60, external 
rotation and internal rotation in abduction are 0, external rotation at side 15, and internal rotation to the buttock.  
 The exam of the left shoulder reveals active and passive range of motion exhibits glenohumeral ankylosis with 
forward flexion to 100, abduction 80, external rotation in abduction is 40, internal rotation in abduction is 0, 
external rotation at side 35, and internal rotation to the sacrum. 
 
However, detailed documentation is not evident regarding trial and failure of recent, reasonable, and 
comprehensive less invasive conservative care measures. Her therapy has only been attended for 10 sessions as 
of September 6, 2022 (with a therapy treatment plan of 24 sessions at 2 visits per week). The surgery was 
requested on the September 12, 2022, exam, well before the recommended physical therapy has been 
completed. Therefore, therapy has not been trialed and failed. Additionally, there was no indication that any 
injection therapies have been trialed. 
 
The large-scale, long-term peer-reviewed literature states that surgical options should be reserved for cases of 
frozen shoulder/adhesive capsulitis refractory to all conservative measures. There are limited large-scale, long-
term references showing the safety and efficacy of the requested surgery in this clinical setting. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception to guidelines. Therefore, the requested fixation of the shoulder x2 (CPT 23700- 
manipulation under anesthesia), 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 fixation of shoulder (23700) have not been met. Therefore, we decided that the 
Plan does not have to pre-approve fixation of shoulder (23700).