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

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for thumb surgery. As noted in the medical literature, the management of patients with painful bilateral thumb osteoarthrosis includes treatment beginning with simple conservative treatments such as activity modification, bracing, or exercise, progressing to pain medications and injections, and reserving surgical treatment as a final option. In this case, it is documented the patient has experienced progressively painful arthrosis at the base of both thumbs, worse on the left. The records document that the patient’s symptoms have been progressively painful and limiting despite years of conservative nonsurgical treatment including rest, bracing, activity modification, and three corticosteroid injections. The patient was found to have correlating findings on clinical examination and x-rays.

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for urgent care services and/or emergency medical services. Findings: The physician reviewer found that this patient received urgent care services and emergency medical services on the date of service in question. The medical literature supports that this patient’s injury required prompt diagnosis and surgical intervention. The provided medical records, specifically the ultrasound performed, corroborate a significant tendon tear. One pair of authors note that, “This type of injury requires prompt diagnosis and surgical repair, as the patellar tendon is a part of the extensor mechanism. The extensor mechanism of the knee is crucial to the function of the lower extremity, including ambulation.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for any or all of the components of the requested left shoulder surgical procedure including arthroscopy, shoulder, surgical, with rotator cuff repair; tenodesis for rupture of long tendon of biceps; and/or arthroscopy, shoulder, surgical, debridement, extensive, three or more discrete structures. Researchers report, “In spite of a dramatic increase in the number of publications per year, there is little evidence that the results of rotator cuff repair are improving. The information needed to guide the management of this commonly treated and costly condition is seriously deficient.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage a standing computed tomography (CT) scan. Bernasconi and colleagues state, “Over the last years, an increased number of studies have reported the use of cone beam weightbearing computed tomography (WBCT) in the assessment of foot and ankle pathology. This new technology has enabled to overcome the limits inherently related to two-dimensional radiographs (superimposition bias, operator-related bias, rotation bias) and to obtain images reproducing the bones and joints anatomy during physiological standing with a low radiation dose.” Godoy-Santos and colleagues state, “Cone-beam computed tomography (CBCT) has been applied in dentistry and medicine for nearly two decades. Its application in the foot and ankle specialty has grown exponentially in recent years.

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