HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 

Medical Policy:
S-260-001
Topic:
Shoulder Surgery – Arthroscopic and Open Procedures
Section:
Surgery
Effective Date:
October 1, 2018
Issued Date:
October 1, 2018
Last Revision Date:
April 2018
Annual Review:
April 2018
 
 

Sprain/Strain/Tear can be defined as overstretching or tearing of the ligament/muscle/tendon and is typically graded on a severity scale of I, II or III:

  • Grade I: mild sprain/strain caused by overstretching or slight tearing of the ligament/muscle/tendon with no instability and has minimal pain, swelling, and little or no loss of functional ability associated with it.
  • Grade II: sprain/strain caused by incomplete tearing of the ligament/muscle/tendon and is characterized by bruising, moderate pain, and swelling; “partial thickness tear.”
  • Grade III: sprain/strain that result in complete tear or rupture of a ligament/muscle/tendon; “full thickness tear.”

Labral tears result when the glenoid labrum becomes injured or torn. Tears are typically classified by the position of the tear in relation to the glenoid.

Bankart tear is a tear in the labrum located in the front, lower (anterior, inferior) part of the shoulder socket. This type of tear occurs most commonly during a shoulder dislocation and makes the shoulder more prone to recurrent dislocations.

SLAP tear (Superior Labral, Anterior and Posterior tear) is a tear in the labrum that covers the top part of the shoulder socket from the front to back. A SLAP tear occurs at the point where the long head of biceps tendon attaches. This type of tear occurs most commonly during falls on an outstretched arm.

  • Classification of SLAP tears:
    • Type I SLAP lesions are described as being indicative of isolated fraying of the superior labrum with a firm attachment of the labrum to the glenoid.
    • Type II SLAP lesions are characterized by detachment of the superior labrum and the origin of the tendon of the long head of the biceps brachii from the glenoid resulting in instability of the biceps-labral anchor.
    • Type III SLAP lesions are characterized by a bucket-handle tear of the labrum with an intact biceps insertion.
    • Type IV SLAP lesions have a bucket-handle tear of the labrum that extends into the biceps tendon. In this lesion, instability of the biceps-labrum anchor is also present.
    • Type V SLAP lesions are characterized by the presence of a Bankart lesion of the anterior capsule that extends into the anterior superior labrum.
    • Type VI SLAP lesions involve a disruption of the biceps tendon anchor with an anterior or posterior superior labral flap tear.
    • Type VII SLAP lesions are described as the extension of a SLAP lesion anteriorly to involve the area inferior to the middle glenohumeral ligament.

Shoulder Dislocation is defined as the complete loss of the humeral articulation with the glenoid fossa, usually as a result of acute trauma.

Shoulder Subluxation is defined as a partial loss of humeral articulation with the glenoid fossa (incomplete or partial dislocation) usually as a result of repetitive trauma to the degree that symptoms are produced.

Shoulder Instability/Laxity is defined as a partial loss of the glenohumeral articulation.  Two categories:

  • Post traumatic shoulder instability includes an individual with a previous injury that has stretched or torn the ligaments of the shoulder.
  • Atraumatic instability/loose shoulder joint includes an individual with generalized looseness of the joints “double-jointed” or “multi-directional instability” usually representing a type of congenital ligamentous laxity.

Impingement syndrome commonly results from friction, abrasion, and inflammation of the rotator cuff and the long head of the biceps tendon with the subacromial arch (anterior lip of the acromion, coracoacromial ligament, and acromioclavicular joint) from acute trauma, repetitive use or degenerative changes.

  • Adhesive Capsulitis is a condition of the shoulder characterized by stiffness, loss of motion (contracture), and pain. Often called frozen shoulder, adhesive capsulitis is clinically divided into classes:
  • Primary adhesive capsulitis is characterized by a significant limitation of both active and passive motions on the shoulder; individuals are typically unable to recall a possible cause of the condition (idiopathic adhesive capsulitis).
  • Secondary adhesive capsulitis is characterized by a trauma or a possible cause prior to the onset of the symptoms, such as fracture of the humerus, rotator cuff repair, shoulder girdle injury/surgery, or prolonged immobilization.
  • Conditions that have been suggested to predispose an individual to adhesive capsulitis are trauma, surgery to the shoulder, inflammatory diseases, diabetes, hyperthyroidism, dyslipidemia.

Non-surgical care with regard to the treatment of the shoulder is defined as any non- surgical treatment which has been demonstrated in the scientific literature as efficacious and/or is considered a standard of care in the treatment of shoulder pain. The types of treatment involved can include, but are not limited to: ice relative rest/activity modification, manual therapy, physical modalities, supervised therapeutic exercise, oral medications, and/or injections (steroid).

Magnetic Resonance Imaging (MRI) is an imaging technique which utilizes radio waves and a powerful magnet linked to a computer to produce a set of detailed images of organs and soft tissue structures of the body.

Computed Tomography (CT) scan is an imaging technique which utilizes a 360- degree x-ray beam and computer to produce a set of cross-sectional images of the body. The individual is exposed to ionizing radiation. CT is also known as computerized axial tomography or CAT scan.

Arthrogram is a series of images of a joint after injection of a contrast medium. Shoulder arthrograms are commonly used to outline structures such as the rotator cull, glenoid labrum, bicipital tendon and sheath. In disease or injury, this contrast fluid may either leak into an area where it does not belong, indicating a tear or opening, or be blocked from entering an area where there normally is an opening.

Diagnostic Ultrasound is an imaging technique which utilizes high-energy sound waves (ultrasound) through a transducer which are bounced off internal tissues or organs which then results in echoes. The echo patterns are then received and shown on the screen of an ultrasound machine, forming a picture of body tissues called a sonogram. Distal Clavicular Excision is the removal of the end of the clavicle. The superior AC ligament remains intact so that the joint remains stable.

Acromioplasty is the removal of bone from the acromion and partial resection of the coracoacromial ligament.

Subacromial Decompression is the removal of bone or other abnormality to widen the space between the rotator cuff musculature and the acromion.

Policy Position Coverage is subject to the specific terms of the member's benefit plan.

A shoulder arthroscopic or open procedure may be considered medically necessary in an individual on whom surgery is being performed for fracture, tumor, infection or foreign body that has led to or will likely lead to progressive destruction.

A shoulder arthroscopic or open procedure may be considered medically necessary for a disease process (e.g., synovectomy for rheumatoid arthritis [RA]) when the symptoms are severe and persistent, and ALL of the following criteria are met:

·         Documented loss of shoulder function which interferes with the ability to carry out age appropriate activities of daily living and/or demands of employment; and

·         Failure of non-surgical management for at least three (3) months in duration; and

·         Appropriate diagnostic technology (i.e., MRI, diagnostic arthroscopy) is determined to be conclusive for damage consistent with the individual’s reported medical condition.

 

 

Diagnostic Arthroscopy

 

Diagnostic arthroscopy may be considered medically necessary when ALL of the following criteria have been met:

·         Severe, disabling pain and/or a documented loss of shoulder function which interferes with the ability to carry out age appropriate activities of daily living and/or demands of employment; and

·         Individual demonstrates ANY of the following abnormal, shoulder physical examination findings as compared to the non-involved side:

o    Functionally limited range of motion (active or passive); or

o    Measurable loss in strength; or

o    Positive impingement signs; and

·         Failure of non-surgical management for at least three (3) months in duration: and

·         Individual has undergone an appropriate radiographic work-up that includes an MRI evaluation which is determined to be inconclusive for internal derangement/pathology; and

·         Other potential diagnostic conditions including but not limited to fracture, Thoracic Outlet Syndrome, Brachial Plexus disorders, referred neck pain and arthritis have been excluded.

 

 

Rotator Cuff Repair

 

Rotator cuff repair may be considered medically necessary when ALL of the following criteria have been met:

·         Individual has severe, disabling pain and/or documented loss of shoulder function to the extent which interferes with ability to carry out age appropriate activities of daily living and/or demands of employment; and

·         Individual demonstrates BOTH of the following when compared to the non-involved side:

o    ONE OR MORE of the following positive orthopedic tests

§  Neer Impingement Test; or

§  Drop Arm Test; or

§  Hawkins Kennedy Impingement Test; or

§  Painful Arc Test

o    AND EITHER of the following :

§  Functionally limited range of motion; or

§  Measurable loss of strength of the rotator cuff musculature; and

·         Advanced diagnostic imaging (e.g., MRI, CT Scan, Diagnostic Ultrasound) demonstrates partial or full thickness (Grade II or III) rotator cuff tear that correlates with the individual’s reported symptoms and physical exam findings; and

·         Failure of non-surgical management for at least eight (8) weeks in duration (with the exception of the individual who suffers a trauma that results in an acute complete tear AND associated disabling pain and loss of function); and

·         Other potential diagnostic conditions including but not limited to fracture, Thoracic Outlet Syndrome, Brachial Plexus disorders, referred neck pain and arthritis have been excluded.

 

Rotator cuff debridement may be considered medically necessary when performed in conjunction with other medically necessary arthroscopic procedures of the shoulder (i.e., subacromial decompression).

Rotator cuff repair is considered NOT medically necessary for all other indications.

 

 

Labral Tear/Bicipital Tendonitis/Tendonopathy Debridement of Repair

 

Labral tear/Bicipital tendonitis debridement or repair may be considered medically necessary when ALL of the following criteria have been met:

·         Severe, disabling pain and/or a documented loss of shoulder function which interferes with the ability to carry out age appropriate activities of daily living and/or demands of employment; and

·         Individual demonstrates BOTH of the following abnormal, shoulder physical examination findings, as compared to the non-involved side:

o    Minimally limited or full shoulder range of motion; and

o    One or more positive orthopedic tests (e.g., O’Brien’s Test (labral or biceps tendon pathology), Anterior or Posterior Apprehension Test, Sulcus Test, Speeds Test); and

·         Advanced diagnostic imaging procedure demonstrates labral tear/bicipital tendon pathology (e.g., SLAP, Bankart) and correlates with the individual’s reported symptoms and physical exam findings; and

·         Failure of non-surgical management for at least six (6) weeks in duration; and

·         Other potential diagnostic conditions including but not limited to fracture, Thoracic Outlet Syndrome, Brachial Plexus disorders, referred neck pain and arthritis have been excluded.

Labral tear/Bicipital tendonitis repair may be considered medically necessary when performed in conjunction with the other medically necessary arthroscopic or open procedures of the shoulder (e.g., Rotator Cuff Repair).

Labral tear/bicipital tendonitis repair is considered NOT medically necessary for all other indications.

 

 

Subacromial Decompression/Acromioplasty/Distal Clavicular Excision

 

Subacromial decompression/acromioplasty and/or distal excision may be considered medically necessary when ALL of the following criteria have been met:

·         Severe, disabling pain and/or documented loss of shoulder function which interferes with the ability to carry out age appropriate activities of daily living and/or demands of employment; and

·         Individual demonstrates local tenderness of the acromioclavicular joint and BOTH of the following compared to the non-involved side:

o    EITHER of the following:

§  Limited active shoulder ROM; or

§  Loss of functional strength of the shoulder; and

o    ONE OR MORE of the following positive orthopedic tests:

§  Cross Arm Adduction Test; or

§  Arm Extension Test; or

§  Neer Impingement Test; or

§  Hawkins Kennedy Impingement Test; or

§  Painful Arc Test; and

·         Failure of non-surgical management for at least eight (8) weeks in duration; and

·         Plain radiographs demonstrate findings consistent with pathology in the subacromial space and/or at the AC joint; and

·         Advanced diagnostic imaging procedure (e.g., MRI, CT Scan) demonstrates underlying pathology (e.g., chronic arthritis, rotator cuff impingement syndrome, etc.) which correlates with the individual’s reported symptoms and physical exam findings; and

·         Other potential diagnostic conditions including but not limited to fracture, Thoracic Outlet Syndrome, Brachial Plexus disorders, referred neck pain and arthritis have been excluded.

Subacromial decompression/acromioplasty/distal clavicle excision may be considered medically necessary when performed in conjunction with other medically necessary arthroscopic or open procedures of the shoulder (i.e., Rotator Cuff Repair).

 

 

Athroscopic Capsular Release/Manipulation Under Anesthesia (MUA) Adhesive Capsulitis

 

Arthroscopic capsular release/MUA for an individual with documented chronic refractory adhesive capsulitis which has resulted from disease, injury or surgery may be considered medically necessary when ALL of the following criteria have been met:

·         Severe, disabling pain and/or documented loss of shoulder function which interferes with the ability to carry out age appropriate activities of daily living and/or demands of employment for at least six (6) months in duration; and

·         Individual demonstrates ALL of the following abnormal, shoulder physical examination findings, as compared to the non-involved side:

o    Functionally limited global loss of active range of motion of AT LEAST 50% as compared to the contralateral side; and

o    Functionally limited and painful global loss of passive range of motion of AT LEAST 50%; and

o    ONE OR MORE of the following positive orthopedic tests:

§  External Rotation Test; or

§  Neer Impingement Test; or

§  Hawkins Kennedy Impingement Test; or

§  Painful Arc Test; or

§  Appley’s Scratch Test; and

·         Failure of non-surgical management that includes a combination of anti-inflammatory medications, cortisone injection and physical therapy, for at least six (6) weeks in duration to determine if treatment is successful; and

·         Other potential diagnostic conditions including but not limited to fracture, Thoracic Outlet Syndrome, Brachial Plexus disorders, referred neck pain and arthritis have been excluded.

MUA should be performed in conjunction with an active rehabilitation/therapeutic exercise program.

 

Manipulation performed in isolation without the individual participating in an active rehabilitation program in conjunction with a home exercise program is experimental/investigational and therefore non-covered because the safety and effectiveness of this service cannot be established by the available published peer-reviewed literature,

 

Arthroscopic capsular release or MUA is experimental/investigational for all other indications and therefore non-covered because the safety and effectiveness of this service cannot be established by the available published peer-reviewed literature,

 

 

Arthroscopic or Open Procedures for Chronic Shoulder Instability/Laxity

 

Arthroscopic or open procedures for shoulder instability/laxity may be considered medically necessary when ALL of the following criteria have been met:

·         Documented history of “post-traumatic” or “atraumatic” instability that has resulted in either severe disabling pain and/or loss of shoulder function which interferes with the ability to carry out age appropriate activities of daily living and/or demands of employment; and

·         Failure of non-surgical management that includes shoulder stabilization/strengthening exercises for at least eight (8) weeks in duration; and

·         One or more positive orthopedic tests for shoulder instability (e.g., O’Brien’s Test, Anterior or Posterior Apprehension Test, Sulcus Test).

An arthroscopic or open surgical stabilization procedure may be considered medically necessary for an acute traumatic irreducible shoulder dislocation.

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Place of Service: Inpatient/Outpatient

Experimental/Investigational (E/I) services are not covered regardless of place of service.

Shoulder surgery is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.


The policy position applies to all commercial lines of business


Denial Statements

Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

Services that do not meet the criteria of this policy will be considered experimental/investigational (E/I). A network provider can bill the member for the experimental/investigational service. The provider must give advance written notice informing the member that the service has been deemed E/I. The member must be provided with an estimate of the cost and the member must agree in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.



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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

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The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

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  • Qualified sign language interpreters
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  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
  • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

    Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.