Are CPT codes 25310, 25350, 25355, 25360, 25365, 25370, and 25375 medically necessary for a 9-year-old boy with birth brachial plexus palsy (Brachial Plexus Disorders, G54.0) on the left upper extremity?

Medical Necessity Determination for Multiple Forearm Procedures in Birth Brachial Plexus Palsy

Yes, the planned procedures (CPT 25310,25350,25355,25360,25365,25370,25375) are medically necessary for this 9-year-old boy with birth brachial plexus palsy who has failed conservative management and demonstrates significant functional impairment with fixed supination contracture and wrist deformity.

Clinical Justification Based on Guidelines

Pediatric Orthopedic Specialist Referral Criteria Met

This patient appropriately requires care from a pediatric orthopedic surgeon based on established referral guidelines 1:

• Congenital limb malformation (birth brachial plexus palsy with resultant forearm deformity) 1
• Significant limb deformity secondary to neuromuscular condition requiring corrective surgery 1
• Disability and gait/limb abnormality secondary to neuromuscular conditions including brachial plexus injuries 1

MCG Criteria Satisfaction

The procedures meet MCG musculoskeletal surgery guidelines [@Question Context@]:

• CPT 25310 (tendon transfer): Indicated for musculoskeletal congenital or acquired dysfunction requiring tendon transfer [@Question Context@]
• CPT 25350-25375 (osteotomies): Indicated for bone repositioning procedures needed for congenital or posttraumatic deformity [@Question Context@]

Evidence-Based Surgical Approach

Tendon Transfer (CPT 25310)

Biceps rerouting with tendon transfer is medically necessary for this patient's fixed supination contracture 2, 3:

• The patient demonstrates unopposed supination by the biceps with paralysis of pronators (forearm pronation active: -90 degrees, passive: 90 degrees) 2
• Biceps rerouting converts the biceps from a supinator to a pronator while preserving elbow flexion function 2
• Published outcomes show 87-degree improvement in forearm position with 91% of patients achieving at least neutral rotation 2
• Functional improvement without loss of supination-dependent function has been demonstrated in retrospective cohort studies 4

Forearm Osteotomies (CPT 25350,25355,25360,25365,25370,25375)

Single or multiple bone osteotomies are medically necessary to correct the fixed rotational deformity 3, 4:

• The patient has mild dysplasia with ulnar deviation and decreased scaphoid ossification on radiographs, indicating structural bone deformity requiring correction [@Question Context@]
• Forearm pronation osteotomy improves resting position by approximately 90 degrees to near-neutral without loss of hand motor skills 4
• Both-bone forearm rotational osteotomy is the established surgical approach for fixed supination contracture in brachial plexus palsy 4
• The specific combination of osteotomies (radius and/or ulna at various levels) depends on the exact location and severity of the dysplasia and rotational deformity identified on imaging 3

Failed Conservative Management Documentation

This patient has exhausted appropriate non-operative treatment 5, 6:

• Multiple prior procedures including neuroma resection, nerve grafting, and nerve transfers [@Question Context@]
• Botox injections to pectoralis and triceps [@Question Context@]
• Physical therapy and bracing with continued functional limitation [@Question Context@]
• Persistent weakness despite interventions, with Active Movement Scale scores showing significant deficits (forearm pronation: 0, supination: 3, wrist extension: 2) [@Question Context@]

Functional Impairment Justification

The patient demonstrates significant functional limitations warranting surgical intervention 4, 5:

• Mallet Classification Total Score of 20/30 indicates moderate shoulder dysfunction [@Question Context@]
• Forearm locked in supination (-90 degrees active pronation) preventing desk activities, writing, and tool use 4
• Wrist extension with ulnar deviation (ECU overpull) without FCU/FCR function [@Question Context@]
• Weak grasp with reasonable finger flexion but compromised by wrist position [@Question Context@]

Age-Appropriate Timing

Surgery at age 9 is appropriate timing for these reconstructive procedures 5, 6:

• Secondary procedures (tendon transfers and osteotomies) are typically performed in children after failed nerve recovery, which this patient has demonstrated 5
• Prevention of progressive deformity during growth is a key indication for intervention in obstetric brachial plexus palsy 2
• The patient has had sufficient time for nerve regeneration (multiple years post-nerve surgery) without adequate functional recovery 6

Critical Procedural Considerations

All Listed Procedures May Not Be Performed Simultaneously

The surgeon has indicated all procedures are "planned," but the actual combination performed will depend on intraoperative findings 3:

• Patient selection and individualized treatment planning based on disability, parental expectations, and existing motor power is crucial 3
• The specific osteotomy levels (distal, middle, or proximal radius/ulna) depend on the exact location of dysplasia and deformity [@Question Context@]
• Single-bone versus both-bone osteotomy depends on whether isolated radius or combined radius-ulna correction is needed 4

Expected Outcomes

Realistic outcome expectations should be discussed 4, 5:

• Improved neutral to mild pronation-dependent function without loss of supination-dependent function 4
• Enhanced spontaneous posture with more normal anatomic relationship of ulna and radius 2
• Improved activities of daily living including eating, dressing, and writing 2
• No guarantee of full active pronation, but significant functional improvement in hand positioning 4

Common Pitfalls to Avoid

• Do not deny based on multiple CPT codes listed: The surgeon appropriately listed all possible procedures, with final selection based on intraoperative assessment 3
• Do not require "one procedure at a time" approach: Combined tendon transfer and osteotomy is the established surgical approach for this condition 2, 4
• Do not delay surgery further: The patient has already undergone extensive conservative management without adequate improvement 5, 6