Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right endoscopic versus open carpal tunnel release with 
right index trigger finger release. 
 
You asked the Plan to pre-approve right endoscopic versus open carpal tunnel release with right index trigger 
finger release. You say that the requested right endoscopic versus open carpal tunnel release with right index 
trigger finger release is medically necessary.  The Plan denied your request. The Plan says the requested right 
endoscopic versus open carpal tunnel release with right index trigger finger release 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 right endoscopic versus open carpal 
tunnel release with right index trigger finger release. Our reviewer says that the requested right endoscopic 
versus open carpal tunnel release with right index trigger finger release is not medically necessary.  Our physician reviewer found the enrollee was being treated for carpal tunnel syndrome of the right upper limb and 
trigger finger of the left index finger. She presented with right-hand pain that began several months ago and 
getting progressively worse. The pain is sharp and burning to her right-hand digits. Pain is more prominent on 
the right index finger, which seems to lock in flexion. There is constant daytime numbness and tingling of 
digits. Numbness is worse at night and wakes her up from sleep. The exam of the right hand reveals moderate 
tenderness to palpation over the right index finger A1 pulley with active triggering. Sensation to light touch 
subjectively decreased along median nerve distribution. Flexion compression test is negative but produces pain 
on the right wrist. 
 
However, detailed documentation regarding a trial and failure of recent, reasonable, comprehensive, less 
invasive conservative care measures is not evident. Additionally, the objective examination did not 
comprehensively detail/corroborate multiple findings compatible with carpal tunnel syndrome. There are 
limited large-scale, long-term references showing the safety and efficacy of the requested surgery in this 
clinical setting. No compelling rationale is presented, or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the requested right endoscopic versus open carpal 
tunnel release with right index trigger finger release, 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 right endoscopic versus open carpal tunnel release with right index trigger 
finger release have not been met. Therefore, we decided that the Plan does not have to pre-approve right 
endoscopic versus open carpal tunnel release with right index trigger finger release.