Carpal Tunnel Syndrome: when insurers say no, reviewers often say yes

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for urgent medical services. One study notes that, “Distal radius fractures… are commonly the result of a fall on outstretched hands or high-energy trauma. On assessment, clinicians should determine the mechanism of injury, associated bony or soft tissue injuries, and neurovascular symptoms. Investigations should always include radiographs to evaluate for intra-articular involvement and fracture displacement. The preferred management should consider the severity of the fracture, desired functional outcome and patient comorbidities. Non-operative management in select patients can give good results. Immobilization with or without reduction forms the mainstay of non-operative treatment.

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for tramadol HCL. According to research, the use of a weak opioid in combination with an NSAID for pain control is indicated for mild to moderate pain and represents only the second step in the four-step ladder. Researchers have stated that medical necessity for chronic opioid therapy may be established on average moderate to severe pain (equal to 4, on a scale of 0 to 10) and/or disability. With regard to determining opioid dosage, researchers consider up to 40 morphine milligram equivalent (MME) as a low dose, from 41 to 90 MME as a moderate dose, and greater than 91 MME as a high dose. Medical literature states that clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with right carpal tunnel syndrome and complex regional pain syndrome (CRPS). The provider noted that the patient underwent a right carpal tunnel release that was complicated by a postoperative infection requiring an incision and drainage procedure. The provider noted the patient had findings consistent with CRPS, including hyperhidrosis of the right-hand fingers, shiny skin, and nerve pain with proximal radiation. The patient was previously treated with a stellate ganglion block, which reportedly was not beneficial. The patient has also been treated with Lyrica and Valium. The patient was noted to be allergic to Pamelor, and she did not want to try another nerve pain medication. The provider noted a second surgery to release scar tissue could be beneficial.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for platelet-rich plasma injection to the right elbow. Platelet-rich plasma injection therapy is a technique using a concentrated portion of autologous blood in an attempt to augment and accelerate healing of various tissues. Review studies and national guidelines have not reported substantial improvement in patient health outcomes with use of platelet-rich plasma for the treatment of musculoskeletal disorders. Currently, data suggest that the use of platelet-rich plasma for most musculoskeletal soft tissue injuries should occur within the context of a well-designed clinical trial. There is a paucity of studies demonstrating the safety and efficacy of platelet-rich plasma for the treatment of chronic pain.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for carpal tunnel syndrome was denied, the published record says the denial is worth fighting.