Shoulder Pain denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1: The patient is a 16-year-old female with a history of pelvic/groin pain. She has migratory pain in the lower abdominal quadrants and groin, right side greater than left. The pain is constant and always present, but can increase to as high as 7/10. She also complains of shoulder pain. She has a history of chronic bilateral frontal headaches, reported as migraines. She has undergone extensive workup in the past for the cause of her pain. Workup included multiple negative laboratory examinations, CT scans and abdominal pelvic ultrasounds. It also included extensive physical evaluations by multiple physicians. The patient has been evaluated and treated by a psychotherapist who feels no significant psychopathology is present. She has taken multiple medications including large doses of neuropathic pain medications such as Neurontin, trileptal, lidocaine and Ultram.

Findings: The physician reviewer found that the patient requested authorization and coverage for Oxycodone HCL 20mg tablets. The Centers for Disease Control and Prevention (CDC) guidelines for opioid therapy prescribing state that, “For patients already receiving opioid therapy, clinicians should carefully weigh benefits and risks and exercise care when changing opioid dosage. If benefits outweigh risks of continued opioid therapy, clinicians should work closely with patients to optimize nonopioid therapies while continuing opioid therapy”. Further, the CDC advised that clinicians should optimize other therapies and work closely with patients to gradually taper to lower dosages or, if warranted based on the individual circumstances of the patient, appropriately taper and discontinue opioids so long as the benefits do not outweigh the risks of continued opioid therapy.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for components for an otherwise authorized right shoulder arthroscopic surgical procedure.There are limited large-scale, long-term studies showing the safety and efficacy of the requested components of the otherwise authorized right shoulder arthroscopic surgical procedure in this patient’s clinical setting.Regarding the arthroscopic capsulorrhaphy, one study found that the requested procedure is an effective method for reducing pain and recurrence of shoulder dislocation. However, detailed documentation is not evident in this case regarding any shoulder dislocations.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for right shoulder magnetic resonance imaging (MRI) with contrast. Researchers explain, “Shoulder pain is one of the most common musculoskeletal complaints. Studies have shown an annual incidence of 14.7 per 1000 patients and a lifetime prevalence up to 70%. Shoulder pain affects work productivity, activities of daily life, and quality of life. Internal derangements of the shoulder including diseases of the muscles and tendons, joints, and labroligamentous and periarticular structures are common causes of shoulder pain. Diagnostic imaging has become increasingly important for the evaluation of these structures. MRI is a crucial diagnostic tool with its multiplanar imaging, high resolution, and lack of ionising radiation.

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 shoulder pain, then check the rights and deadlines that apply to your plan.