Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left Shoulder Problem/Pain. 
Treatment: Surgical Services (left shoulder surgery). 
The health plan denied the requested left shoulder surgery as not medically necessary. 
The health plan's determination is partially overturned. 

The patient is a female who presented with a history of left shoulder, left wrist and left-sided neck pain. She sustained a fall at a playground. She did not lose consciousness at that time. She fell onto her bilateral outstretched arms. The patient has been evaluated by orthopedic surgery as well as pain management. The patient works as a corrections officer. She does have a history of a previous left subdeltoid and proximal biceps injection. She underwent additional injections. The patient also attempted physical therapy for her left shoulder. She has attempted over 12 weeks of anti-inflammatory medication. She has attempted over 12 weeks of home exercise and physical therapy, as well. Her pain interferes with her activities of daily living, including dressing, showering, and social activities. Despite these interventions, she did have severe pain anteriorly and with overhead activity. On examination, she does have markedly positive impingement signs, with tenderness to palpation in the bicipital groove. She does have positive cross arm exam and tenderness over the acromioclavicular (AC) joint. A magnetic resonance imaging (MRI) of the left shoulder demonstrates a superior labrum anterior posterior tear with diffuse rotator cuff tendinosis. There is mild biceps tenosynovitis and acromioclavicular joint hypertrophy. She has been recommended for a left shoulder arthroscopy with subacromial decompression, possible Mumford, open biceps tenodesis, rotator cuff repair and possible SLAP repair. 

I overturn, in part, the health plan's determination of medical necessity, based on the appeal documentation. Current Procedural Terminology (CPT) 29824, 29828, and 29807 are considered medically necessary at this time based on the appeal documentation from the treating surgeon. 
CPTs 29827 and 29826 are not considered medically necessary at this time. 

In regard to Mumford procedure, biceps tenodesis, and possible minimally invasive surgery using an arthroscope (SLAP) repair, these procedures are considered medically necessary at this time based on the failure of conservative treatment and associated MRI findings. 

In regard to subacromial decompression and rotator cuff repair, these services are not considered medically necessary. Subacromial decompression has not been shown to be beneficial in regard to pain and improvements in function. Patients who underwent subacromial decompression do not show improved outcomes to placebo treatment in the setting of rotator cuff repair. In regard to rotator cuff repair, the MRI does not demonstrate high-grade partial-thickness tearing or full-thickness tearing of the rotator cuff.

In regard to Mumford procedure (distal clavicle excision), this procedure is considered medically necessary at this time. The patient does have MRI findings consistent with moderate to severe acromioclavicular joint arthritis. She has attempted conservative treatment for over 7 months including injections, physical therapy, and activity modification. She is also taking anti-inflammatory medication for over 7 months. She does have tenderness over the acromioclavicular joint and positive pain with cross body adduction. Therefore, distal clavicle excision is considered medically necessary at this time. 

In regard to biceps tenodesis and possible Superior Labrum, Anterior to Posterior (SLAP) repair, the patient does have a SLAP lesion based on the MRI findings. She does have positive tenderness to palpation over the biceps as well as impingement signs. She has attempted conservative treatment for over 7 months including injections into the biceps which provided temporary relief as well as physical therapy. She has attempted anti-inflammatory medications as well. Given her continued symptoms affecting her activities of daily living, biceps tenodesis or SLAP repair is considered medically necessary at this time.