Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right hip pain
Treatment: Arthroscopy, hip, surgical; with femoroplasty CPT 29914 and anchor screw for opposing bone to bone or soft tissue to bone C1713.
The insurer denied arthroscopy, hip, surgical; with femoroplasty CPT 29914 and anchor screw for opposing bone to bone or soft tissue to bone C1713.
The determination is overturned.


This is a patient with hip pain who underwent hip surgery. Review is requested for right hip arthroscopic femoroplasty (current procedural terminology (CPT) 29914) and use of a surgical anchor (C1713). A health plan letter indicates a labral repair performed on the same date was approved, but the femoroplasty was denied due to a lack of supporting imaging findings and the surgical anchor was denied because the main surgery includes all the hardware necessary for the procedure. A progress report revealed presentation with a multi-year history of right hip pain. The pain was becoming increasingly severe. There was associated popping when going from a seated to a standing position or when walking. The symptoms were limiting her quality of life. The physical examination of the right hip reveals pain with FADIR [Flexion, Adduction, Internal Rotation] test, groin pain with Stinchfield test, no pain with knee range of motion, and good range of motion of the hip. The provider indicated that right hip x-rays showed a well-preserved joint space. The impression was pain. There was a recommendation for a magnetic resonance (MR) arthrogram.
A right hip MR arthrogram radiology report indicates there are changes to the femoral head consistent with underlying cam impingement additional findings consistent with a small labral tear. A progress report indicates the patient has ongoing right hip pain. There is associated popping and catching. The provider states the patient has had extensive physical therapy that has not helped significantly. The physical examination of the right hip reveals 25 degrees () of internal rotation, 25 of external rotation, 110 of flexion, positive FADIR, positive Stinchfield test, and positive outlet impingement test. The provider indicates the diagnostic test findings are consistent with cam type impingement and anterior superior labral tear without obvious osteoarthritic damage. There is a recommendation for an intra-articular injection with the provider noting that if this does not work, the patient is a candidate for hip arthroscopy, labral repair, acetabuloplasty, and femoral neck osteoplasty. A procedure report indicates the patient underwent an imaging guided intra-articular injection with corticosteroid and local anesthetic. At issue is the medical necessity of arthroscopy, hip, surgical; with femoroplasty CPT 29914 and anchor screw for opposing bone to bone or soft tissue to bone C1713.

The procedures are medically necessary.
Regarding femoroplasty (CPT 29914), the right hip MR arthrogram radiology report documents that there are changes to the femoral head consistent with underlying cam impingement. It is also documents that the patient had pain and mechanical symptoms, failed conservative treatment, and had positive impingement testing on physical examination. Given the failure of conservative treatment and the reported clinical and imaging findings, femoroplasty was medically necessary and consistent with the standard of care. As noted in the referenced article from StatPearls, femoroplasty is supported for the treatment of cam impingement after a failure of conservative treatment. Regarding the surgical screw (C1713), the plan approved the performed labral repair, which requires a screw anchor for the repair. As the repair cannot be performed without the anchor screw, the anchor screw was required for the approved labral repair.
Based on the available information, the requested health service/treatment of arthroscopy, hip, surgical; with femoroplasty CPT 29914 and anchor screw for opposing bone to bone or soft tissue to bone C1713 are medically necessary.