Diagnosis: Shoulder pain
Treatment: Joint Surgery (29806-incision of shoulder joint capsule using and endoscope and 29807-repair of shoulder socket cartilage using an endoscope)
The insurer denied the joint surgery (29806-incision of shoulder joint capsule using and endoscope and 29807-repair of shoulder socket cartilage using an endoscope).
The denial is upheld.

The patient is a male with right shoulder pain. He was initially evaluated the previous year. He had reported eight shoulder dislocations. He was referred for an MRI (magnetic resonance imaging) arthrogram and found to have a labral tear. He reportedly was treated with ice, heat, rest and anti-inflammatories. He reportedly could not obtain other services due to COVID. He underwent shoulder surgery.

No, the surgery was not medically necessary.

The applicable criteria are AIM (Anthem, Inc. Medical) Clinical Guidelines. These are generally accepted guidelines in the Orthopedic community. The AIM Clinical Guidelines criteria were not fulfilled.

Per the guidelines criteria for Arthroscopic or Open Procedures for Chronic Shoulder Instability/Laxity, Capsulorrhaphy (Bankart procedure) may be considered medically necessary when ALL of the following criteria are met:
1) History of a shoulder dislocation, MET 2) Positive apprehension/relocation test, MET 3) Shoulder pain and/or instability which interferes with age-appropriate activities of daily living, MET 4) MRI demonstrates at least ONE of the following: a) Bankart/labral lesion b) Hill Sachs lesion MET c) Capsular tear 5) Failure of at least 12 weeks of conservative management (unless has multiple dislocations during management) NOT MET.

The patient did not receive three months of conservative treatment (stabilization/strengthening exercises). Therefore, the procedure would not be indicated. The reported rest and medication would not be considered sufficient. It would be important to provide a course of PT (physical therapy) prior to surgical intervention.