Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary. An enrollee has requested hip joint manipulation under anesthesia for treatment of the enrollees hip pain. Findings: Two physician reviewers found that the records indicated that the patient sustained a right hip femoral neck fracture and underwent open reduction and internal fixation. The treating provider report documented x-ray findings of expected controlled collapse of the fracture. There were some concerns for cortical penetration of the subchondral bone by screw threads in the anterior superior quadrant. The treatment plan included close observation with repeat x-rays to assess screw position and allow six to eight weeks of healing following removal of this screw. The treatment plan included non-weight bearing, activity modification and limited physical therapy. The treating provider report documented x-ray evidence of intact hardware and healing of the fracture. A physical examination documented no crepitance or pain with range of motion of the hip. The diagnosis was closed fracture of the neck of the right femur with routine healing. A hardware removal procedure was scheduled. The operative report documented removal of right hip hardware with fluoroscopic examination under anesthesia with manipulation. The operative description documented removal of the screws. This was followed by manipulation of the leg under live fluoroscopy in internal and external rotation and with flexion and confirmation that the femoral head was well united to the neck and remainder of the femoral shaft. The hip was taken through a gentle range of motion in flexion, abduction and adduction, internal and external rotation. Per the Health Plan, manipulation of the hip under anesthesia was considered investigational as medical studies did not show this treatment was helpful for joints such as the elbow, wrist, hand, finger, pelvis, ankle or the spine. The Health Plan denied reimbursement for the manipulation of the hip under anesthesia. This denial is the subject of this appeal and determination. In this case, the patient sustained a right hip femoral neck fracture and was status post open reduction and internal fixation. The medical records documented that a fixation screw was out of position and hardware removal was recommended following fracture healing to avoid additional subchondral injury. The patient underwent hardware removal with examination under anesthesia, including manipulation of the joint, to assess osseous healing and range of motion. The evidence-based medical guidelines and peer-reviewed literature generally support manipulation under anesthesia in the setting of hip adhesive capsulitis. However, there was no evidence of adhesive capsulitis or limited motion prior to surgery in this patients case. The manipulation under anesthesia was part of the routine operative examination performed and not a separate therapeutic procedure. Therefore, the services at issue were not likely to be more efficacious than any available standard therapy for treatment this patient.Final Result: Two reviewers determined that the issues were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: All three physician reviewers are board certified in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.