Thoracic Outlet Syndrome denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested magnetic resonance imaging/magnetic resonance angiogram (MRI/MRA) for evaluation of her medical condition. Findings: The physician reviewer found that thoracic outlet syndrome (TOS) refers to a group of clinical syndromes caused by congenital or acquired compression of the brachial plexus (neurogenic TOS) or subclavian artery or subclavian vein as they pass through the thoracic inlet. There are multiple modalities utilized to diagnose TOS. These include ultrasound, plain radiographs, contrast-enhanced computed tomography (CT), MRI, or conventional angiography. MRI has become popular in its ability to simultaneously demonstrate the vasculature, bones, and soft tissues, in multiple different projections.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Botox injections.Thoracic outlet syndrome is a difficult condition to diagnose, principally arising from an absence of other causes for arm/shoulder pain as well as typical symptoms and provocative physical maneuvers. In an effort to provide diagnostic accuracy, selective injection of the scalene muscles as well as the pectoralis minor muscle with local anesthetics has been useful in some cases. Guided injection of Botox has also been investigated as a means of both diagnosis and treatment. A study by Salhan and colleagues suggests improvement with Botox injections, notably from a center well-established in the treatment of thoracic outlet syndrome. Botox injections are generally safe with few reported complications.

Where the denial was upheld

Physician 1: The patient is a 46-year-old female who sustained an injury following a motor vehicle accident affecting her right upper extremity leading to a chronic syndrome that has not yet been diagnosed. An MRI scan of the cervical spine reveals evidence of pathology at C5-6 on the right. The patient was evaluated by a neurologist who recommended an MR neurogram to rule out a thoracic outlet syndrome. The Health Plan has denied authorization and coverage for MR neurography on the basis it is considered investigational for evaluation of the patient’s medical condition.The diagnosis of a thoracic outlet syndrome is best made clinically with confirmatory tests (EMG and occasionally vascular tests). A thorough neurological examination including provocative maneuvers is appropriate to rule out the diagnosis.

Findings: The physician reviewer found that a patient has requested authorization and coverage for a Botox injection. The use of Botox for patients with thoracic outlet syndrome (TOS) is based on its ability to induce chemodenervation and muscle relaxation, theoretically reducing the compression on the brachial plexus, which is responsible for neurogenic symptoms. The notion is that by injecting Botox into certain muscles, such as the scalene muscles or pectoralis minor, tension and compression on the neurovascular structures could be relieved, leading to symptomatic improvement. However, this theoretical benefit does not consistently translate into clinical success. The variability in outcomes, as highlighted in multiple studies, suggests that the presumed mechanism of muscle relaxation may not address the complex, multifactorial nature of TOS in many patients.

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 thoracic outlet syndrome, then check the rights and deadlines that apply to your plan.