Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right hip pain
Treatment: Hip Surgery
The insurer denied Hip Surgery.
The determination is overturned.


The patient has a history of right hip pain. Due to persistent hip pain, a magnetic resonance imaging (MRI) scan was obtained which confirmed a labral tear and evidence of femoro-acetabular impingement. After failed conservative treatment, the patient opted for surgical intervention. The patient underwent right hip arthroscopy for removal of a loose body, labral repair and femoral cam lesion resection. At issue in this case is the medical necessity of the hip arthroscopic surgery.

The requested health service/treatment of arthroscopic hip surgery was medically necessary for this patient. The records show that the patient had documented hip pathology on both preoperative computed tomography (CT) scan and magnetic resonance imaging (MRI) scan. The patient failed conservative treatment including an injection and supervised physical therapy. The current, peer-reviewed literature supports the performance of the requested surgery.
The provided medical records document that this active patient had right hip pain for one year. He attempted activity modification, oral nonsteroidal anti-inflammatory drugs (NSAIDs), a four month course of supervised physical therapy and a cortisone injection into the affected right hip which provided only minimal pain relief. A computed tomography (CT) scan of the right hip confirmed findings of femoro-acetabular impingement in the right hip with an alpha angle of 75 degrees and a center edge angle of 23 degrees. An MRI scan of the right hip confirmed that a labral tear was present. Lastly, the treating orthopedic surgeon obtained plan radiographs of the right hip which revealed no evidence of degenerative arthritis - graded Tonnis grade 0. The physical examination of this patient's right hip also confirmed findings consistent with impingement including pain with 90 degrees of hip flexion and internal rotation of the affected right hip. Therefore, based upon the provided medical records, the medical necessity of the arthroscopic hip surgery performed is established because of the objective evidence provided by the MRI and CT scans, the physical examination findings, and the failed conservative treatment for the condition.
A recent article published by Martin and colleagues in the American Journal of Sports Medicine in 2021 concluded that "In patients older than 40 years with limited osteoarthritis, arthroscopic acetabular labral repair with postoperative physical therapy led to better outcomes than physical therapy alone. Thus, age over 40 years should not be considered a contraindication to arthroscopic acetabular labral repair." A second article published by Annin and associates in the Arthroscopy Journal in 2021 concluded that "Athletes undergoing arthroscopic hip surgery in the setting of femoroacetabular impingement, not only exhibit significant functional improvement, but also have a high rate of return to sport at the same or greater competition level compared with preinjury level." Thus, the medical necessity of the surgery performed for this patient is established based upon the provided records and the conclusions of the current, peer-reviewed literature.