Is a triple nerve transfer to reinnervate the deltoid and infraspinatus using CPT (Current Procedural Terminology) 64905 medically necessary for a 26-year-old male with right traumatic brachial plexus palsy, significant upper extremity weakness, and loss of shoulder function, who has not attended therapy, reports compensatory behaviors with nicotine pouches, and has a complex medical history including a pseudomeningocele of the C8 nerve root?

Medical Necessity Assessment for Triple Nerve Transfer in Traumatic Brachial Plexus Palsy

Direct Recommendation

The triple nerve transfer (CPT 64905) to reinnervate the deltoid and infraspinatus is medically necessary for this 26-year-old male with traumatic C5 brachial plexus palsy, complete loss of shoulder function (0/5 abduction and external rotation), and EMG-confirmed limited recovery approximately one year post-injury, despite the absence of documented conservative therapy and concerning nicotine use. 1

Clinical Justification

Severity of Injury and Functional Deficit

• This patient demonstrates complete loss of shoulder function with 0/5 shoulder abduction, 0/5 external rotation, and medial scapular winging, indicating severe C5 nerve root injury with involvement of the deltoid and rotator cuff musculature 1

• The EMG demonstrates very limited recovery of C5 injury that appears relatively proximal given rhomboid involvement, suggesting a poor prognosis for spontaneous recovery 1

• The presence of a pseudomeningocele at C8 on imaging is a surrogate marker for nerve root avulsion, indicating the severity of the plexus injury, though this appears separate from the C5 injury requiring reconstruction 1, 2, 3

• At approximately one year post-injury (injury in [DATE], evaluation in [DATE]), sufficient time has elapsed to determine that spontaneous recovery is unlikely, making surgical intervention appropriate 1, 2

Appropriateness of Nerve Transfer Surgery

• Nerve transfers have become standard of care for traumatic brachial plexus reconstruction, particularly for proximal injuries where the reinnervation distance is shorter and outcomes are superior to traditional nerve grafting 4, 5

• The triple nerve transfer specifically addresses the C5 distribution (deltoid and infraspinatus reinnervation), which is the primary deficit in this patient's presentation 4, 6

• Nerve transfers are appropriate even in older patients when performed within the appropriate timeframe, with successful outcomes reported even in a 74-year-old patient at 16 weeks post-injury 4

• The patient's age of 26 years is optimal for nerve transfer surgery, as younger patients have better neuroplasticity and reinnervation potential 4

Addressing Conservative Treatment Concerns

The lack of documented physical therapy does not preclude surgical candidacy for several critical reasons:

• Physical therapy cannot restore function when there is complete denervation (0/5 strength) and EMG-confirmed lack of nerve recovery—therapy maintains range of motion but cannot create muscle contraction without nerve supply 1

• The patient demonstrates preserved passive range of motion (good PROM noted), indicating that joint contractures have been avoided, which is the primary goal of conservative management in complete nerve injuries 1

• Surgical timing is critical in brachial plexus injuries—delaying surgery beyond 12-18 months significantly compromises outcomes due to irreversible muscle atrophy and motor endplate degeneration, making the absence of formal therapy documentation less relevant than the surgical window 4, 5

• The patient reports "functional improvement largely due to compensation behaviors," indicating he has maintained activity and prevented complete disuse, which is the functional equivalent of therapy goals in this context 1

Nicotine Use Consideration

• While nicotine use is a relative concern for peripheral nerve healing, it is not an absolute contraindication to nerve transfer surgery 4

• The patient should be counseled on smoking/nicotine cessation to optimize surgical outcomes, but this should not delay surgery beyond the critical 12-18 month window 4

• Nicotine cessation can be implemented as a perioperative optimization strategy rather than a barrier to approval 4

Pain Management Documentation

• The clinical note states "pain well managed" and the patient "reports that symptoms have not improved since onset" but does not describe significant pain as a primary complaint 1

• In brachial plexus injuries with complete denervation, pain is often less prominent than functional deficit, and the absence of documented pain medication use may simply reflect that pain is not the primary problem 1

• The primary indication for nerve transfer is restoration of function, not pain management, making pain medication documentation less relevant to medical necessity 1, 4

Addressing the CPB Reference Discrepancy

Why Obstetric vs. Traumatic Distinction is Not Relevant

• The surgical technique for nerve transfer (CPT 64905) is identical whether the brachial plexus injury is obstetric or traumatic in origin—the procedure involves transferring functioning donor nerves to denervated recipient nerves 4, 5

• The CPB reference to obstetric injuries likely reflects that obstetric brachial plexus palsy is more common in the literature and insurance databases, but traumatic injuries in adults are well-established indications for the same procedures 1, 4

• The MCG criteria for "nerve repair" is met, as this patient requires peripheral nerve operation for traumatic brachial plexus injury 1

• Multiple case reports and series demonstrate successful nerve transfers for traumatic adult brachial plexus injuries, establishing this as standard practice 4, 5, 6

Critical Timing Considerations

Surgical intervention should not be delayed for the following reasons:

• The optimal window for nerve transfer is 3-12 months post-injury, with acceptable results up to 18 months; this patient is approaching the upper limit of this window 4

• Beyond 12-18 months, irreversible muscle atrophy and motor endplate loss occur, making reinnervation impossible even with successful nerve regeneration 4

• Requiring additional conservative therapy documentation would push the patient beyond the surgical window, effectively denying him any chance of functional recovery 4

Common Pitfalls to Avoid

• Do not confuse the inability to perform therapy (due to complete denervation) with failure to attempt conservative management—these patients cannot generate muscle contraction for strengthening 1

• Do not delay surgery for nicotine cessation beyond the critical 12-18 month window—counsel cessation but proceed with surgery 4

• Do not require pain medication documentation when functional deficit, not pain, is the primary indication 1

• Do not reject based on CPB obstetric reference—the surgical technique and indication are identical for traumatic injuries 4, 5

Recommendation Summary

Approve the triple nerve transfer (CPT 64905) as medically necessary. This patient has:

• Complete loss of shoulder function (0/5 strength) with EMG-confirmed poor recovery 1
• Appropriate timing (approximately 12 months post-injury) within the critical surgical window 4
• Preserved passive range of motion indicating adequate joint maintenance 1
• A well-established surgical indication supported by multiple case series and standard practice guidelines 1, 4, 5

Require perioperative nicotine cessation counseling but do not delay surgery, and document that formal physical therapy cannot restore function in the setting of complete denervation but the patient has maintained passive range of motion and functional compensation 4.