Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hip Pain.
Treatment: Total Hip Replacement.
The insurer denied the Total Hip Replacement.
The denial is upheld. 

The patient is female. She had a left hip arthroscopy, labral repair. An urgent request for external appeal indicates "unfortunately she fell some steps 6 weeks postoperatively around, she was treated by another doctor...".

The patient had an MRI (magnetic resonance imaging) arthrogram. Postsurgical changes and thinning of anterior acetabular cartilage and fissuring were noted. The patient had ultrasound-guided steroid injection with "minimal relief." Repeat x-rays of the left hip demonstrated "moderate arthritic changes and she may have a little bit more hip dysplasia on the left versus the right". Repeat MRI (magnetic resonance imaging) of the left hip demonstrates similar findings along the labral degenerative tearing. She was then sent for another left hip ultrasound-guided bupivacaine injection with initial relief after the procedure but worsened pain three hours post-procedure.

A note from the treating provider indicates flexion past 90, internal rotation 10, external rotation 35, tender to palpation laterally. She was sent for a hip injection. Follow-up indicates the patient did go for a Novocain injection to her left hip, which relieved 90% (percent) of her symptoms. Under her care plan, it is noted: "Her pathology is in the hip joint itself she does have arthritic changes".

Report of radiographs of the left hip, AP (anteroposterior) and frog leg view of the left hip demonstrates "the joint spaces appear intact". She had an unremarkable left hip examination.

The patient had ultrasound guided steroid injection into the hip.

An additional letter from the patient was reviewed. In this letter she details a history of her hip pain, and multiple imaging studies, MRI of the hip that has been done. It is noted that she has significant hip pain and has difficulty sleeping.

No, the total hip replacement is not medically necessary.

Based on the report of the latest x-rays available for review, the joint space is preserved. Although this patient has benefited from a bupivacaine injection test in the joint for a reported three hours after the injection, there is no radiographic evidence of Kellegren Lawrence grade III or IV changes on the hip to warrant a hip arthroplasty.

The treating provider indicates that the patient has arthritic changes in her hip based on recent x-rays. However, x-rays from a year ago indicate "joint space is preserved".

Although the patient's provider indicates that the patient is a candidate for a total hip arthroplasty, the current documentation and the x-ray reports do not support a total hip arthroplasty. The patient's hip joint is noted to be preserved on x-rays and no evidence of arthritis is mentioned on these reports, which is in conflict with what the treating provider has indicated in one of the provided notes.

There is no evidence of arthritis on the report of the radiographs available for review to justify or warrant hip arthroplasty.

In absence of evidence of moderate to severe osteoarthritis of the hip on radiographs, hip arthroplasty is not warranted.

There is a lack of evidence in terms of presence of moderate to severe osteoarthritis of the left hip to warrant surgery. Hip pain, especially lateral hip pain after hip arthroscopy, is not justification for a hip replacement.