Diagnosis: Left shoulder pain.

Treatment: arthroscopy, shoulder, surgical; biceps tenodesis (procedure code 29828).

The insurer denied coverage for arthroscopy, shoulder, surgical; biceps tenodesis (procedure code 29828).

The denial is upheld.


This is the case of a patient with a history of left shoulder pain. Per the office visit, the patient has been having symptoms for 1 year. The pain is moderate with a rating of 8/10. The symptoms are constant and has clicking, popping, weakness, and giving way to the left shoulder. According to the clinical notes the patient had physical therapy. An MRI (magnetic resonance imaging) of the left shoulder showed a focal tear of the supraspinatus tendon at the footprint, partial tearing of the infraspinatus tendon, evidence of minimal focal low grade partial tearing of the subscapularis tendon at the footprint and question of an anterior labral tear.

The medical records were inconsistent to substantiate the necessity of surgery. An operation is necessary if there is a defined pain generator and failure to improve with conservative treatment. The facts are the patient has chronic neck pain with radicular symptoms. He has had placement of a spinal cord stimulator and rhizotomy. He was evaluated on several occasions over years and found to have limited to no objective findings of shoulder pathology, i.e. No areas of tenderness, normal motion and normal strength. He was reported to have an impingement sign which is clearly subjective and more than likely related to his radicular complaints (clinical correlation supports this).

His MRI findings would be more consistent with a degenerative process. He has sustained no trauma and it would be extremely unlikely to have a symptomatic SLAP (Superior Labrum Anterior and Posterior) tear. It is a well-known fact many people over 50 have asymptomatic rotator cuff tears. Once again, no trauma occurred which could result in the damage reported.

The final aspect is he had received two cortisone injections over a period of a year. He did not receive other conservative treatments. Notes reflect that patient did physical therapy on his own and one note indicates referral for physical therapy. However, no specifics are provided in the submitted materials.

Based upon the clinical presentation (i.e. chronic cervical radicular pain syndrome, ill-defined pathology consistent with degenerative disease and no data confirming a formal period of physical therapy, the surgery should be denied.

There were no extenuating circumstances to substantiate necessity of operative intervention.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for arthroscopy, shoulder, surgical; biceps tenodesis (procedure code 29828) is not substantiated.