Shoulder Problem: when insurers say no, reviewers often say yes

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.

Physician 1: This patient is a 49-year-old female with a history of refractory migraine and myofascial pain dating back to her multiple motor vehicle accidents in 1987. She states that the muscle pain can trigger her migraines. The patient achieves relief of her migraines with Relpax, but is requiring treatment often (1-2 times per week). Prior preventive treatments have failed including non-steroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants, though no specific mention is made of any trials of migraine preventives. Physical medicine measures have apparently not relieved the patient’s myofascial pain either. The Health Plan has denied the patient’s request for authorization of Botox injections due to their determination that the therapy is experimental/investigational in nature.The patient’s myofascial pain is refractory, and standard pain management approaches have failed.

Where the denial was upheld

Physician 1: The patient is a 42-year-old male who experienced an injury while fighting a fire resulting in shoulder/periscapular pain that has persisted over 1.5 years. He has attempted conventional therapeutics including physical therapy, oral medications, home exercises and trigger injections without relief. Imaging of the spine showed no clinically relevant abnormalities. EMG showed no radiculopathy or plexopathy. A request has been made for authorization and coverage for Botox injections. The Health Plan has denied this request on the basis that Botox is considered investigational in this clinical setting.The patient has a myofascial pain syndrome status post trauma and surgery. The medical literature regarding Botox and pain relief is substantial when looking at dystonia as the underlying diagnosis.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for electromyography (EMG) of the left shoulder blade muscles (supraspinatus plus infraspinatus muscles), nerve conduction study (NCS) of the left shoulder blade muscles (supraspinatus plus infraspinatus muscles), ultrasound of the left shoulder, and magnetic resonance imaging (MRI) with contrast of the left knee for evaluation of his chronic pain and numbness. Findings: The physician reviewer found that the requested EMG and NCS of the left supraspinatus and infraspinatus muscles are not medically necessary for evaluation of this patient’s medical condition.

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 shoulder problem was denied, the published record says the denial is worth fighting.