Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an ultrasonic bone stimulator. Fowler and Hughes state, Scaphoid fractures are the most common carpal bone fracture, usually occurring in young men, although the incidence in women has increased over the past decade. Snuffbox tenderness and/or pain with axial loading of the thumb should be treated as a scaphoid fracture until proved otherwise and the diagnosis confirmed with serial radiographs and/or advanced imaging. Nearly all displaced scaphoid fractures should undergo operative intervention to reduce the risk of nonunion. Nondisplaced fractures have high union rates with cast treatment, but require extended periods of immobilization. Consideration may be given to operative fixation of these fractures to allow early return to sport. Commandeur and colleagues report, Considering that pseudoarthrosis, or non-union, often occurs in patients with scaphoid fractures it is very important to start adequate treatment as soon as possible. On the basis of the literature, we advise immobilization in a below-elbow cast, whereby the thumb is not immobilized and the wrist is in a slightly extended position. Despite the fact that non-dislocated fractures, at the very least, are usually consolidated within four weeks, we advise an immobilization period of six weeks followed by clinical or radiological evaluation. If the fracture fails to consolidate, we advise prolonged immobilization with two-weekly evaluation. There is no evidence in the literature of a positive effect of pulsed electromagnetic field therapy or pulsed low-intensity ultrasound therapy on healing of scaphoid fractures. Arsalan-Werner and colleagues note, Fractures of the scaphoid are common injuries, accounting for approximately 80% of carpal fractures. Differentiation between stable and unstable fractures (Herbert classification) cannot be made with conventional x-rays, so evaluation by computed tomography should additionally be performed. Under most circumstances, minimally invasive surgery with cannulated screws is the treatment of choice. A longer cast immobilization after minimal-invasive surgery is not necessary. Conservative treatment still has a place if the fracture is not dislocated nor unstable, but operative treatment can be offered to reduce the period of cast immobilization. Displaced fractures have a greater risk for nonunion and therefore should be treated operatively. Proximal pole fractures are definitely unstable, requiring treatment with screw fixation. The surgical approach depends on the location of the fracture and the preference of the surgeon. Finally, Pinder and colleagues conclude, Current evidence does not demonstrate a significantly superior method for the treatment of scaphoid nonunion. A multicenter randomized trial would be ideal but the large numbers that would be required may make this unrealistic. We recommend the continued reporting of series with specific assessments and outcome measures to optimize future comparisons in an attempt to determine the best management of scaphoid nonunion. In this case, the patient is being treated for a closed nondisplaced fracture of the middle third of scaphoid of the left wrist with nonunion. The patient had sustained an injury, but her scaphoid fracture was not diagnosed at that time. X-rays demonstrated complete scaphoid waist fracture, with slight distraction and no significant displacement. The patient reported persistent left wrist pain and the records noted treatment with a wrist brace/splint. She is noted to have utilized a wrist brace/splint. An examination reported left wrist motion that was somewhat limited with extension of 30 degrees, flexion of 40 degrees, radial deviation of 20 degrees, and ulnar deviation 30 degrees. She was tender to palpation over the scaphoid at the anatomic snuffbox and the distal pole. Sensation was intact. There is limited published, large-scale, long-term peer-reviewed literature that shows ultrasonic bone growth stimulation to be an effective and/or safe treatment for nonunion of scaphoid fractures, over immobilization alone, and current medical literature supports the use of surgery as a viable treatment option. The records did not document a trial of long-term immobilization without callous/healing demonstrated by serial radiographs. Therefore, an ultrasonic bone stimulator is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.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.