Right Shoulder Pain denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the right hip, MRI of the pelvis, and/or MRI of the right shoulder. Per the American College of Radiology (ACR) guidelines, the requested MRI of the pelvis and right hip are medically necessary for further evaluation of this patient. The records document that the findings visualized on the patient’s prior MRI examination require repeat MRI studies and is consistent with the recommendations from the interpreting radiologist. Per the imaging characteristics, additional evaluation with MRI is appropriate to help determine whether the lesions are malignant (Nascimento, et al.). If the lesions have increased in size since the previous studies, then the patient’s clinical management will be impacted, and may support an indication for biopsy.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for any or all of the chiropractic services provided by Dr. Douglas DeSalvo on 9/21/20, 9/30/20, 10/01/20, 10/05/20, 10/07/20, 10/09/20, 10/12/20, 10/16/20, 10/19/20, 10/23/20, 10/26/20, 10/30/20, and 11/02/20.Evans and colleagues found, “Spinal manipulation combined with exercise was more effective than exercise alone over a 1-year period, with the largest differences occurring at 6 months.” Additionally, Goertz and colleagues concluded, “Chiropractic manipulative therapy (CMT) in conjunction with standard medical care offers a significant advantage for decreasing pain and improving physical functioning when compared with only standard care.” In this case, the patient presented with right shoulder and lower back pain. The patient has chronic pain and has received chiropractic care.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for physical therapy for the neck including traction, physical therapy for the right hip including traction, and physical therapy for the right shoulder. Findings: The physician reviewer found that records provided for review document that this patient has experienced chronic, widespread pain complaints that do not correlate well with her injury history or physical examination findings. She has undergone treatment with physical therapy without significant benefit. The records suggest that independent exercises and modalities are appropriate for this patient.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for acupuncture services and acupressure visits. The available records support a history of right shoulder joint pain and elbow pain. Medical literature shows, “Acupuncture is effective for the treatment of chronic musculoskeletal, headache, and osteoarthritis pain.” Researchers noted, “Referral for a course of acupuncture treatment is a reasonable option for a patient with chronic pain.” Another study noted, “Our review found encouraging evidence for the effectiveness of acupuncture at Tiaokou for shoulder adhesive capsulitis.” In this case, the total number of prior acupuncture sessions completed, and when the care was last rendered, was not documented.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving right shoulder pain, then check the rights and deadlines that apply to your plan.