Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve aspiration and/or injection of major joint or joint 
capsule with recording and reporting using ultrasound guidance. 
 
You asked the Plan to pre-approve aspiration and/or injection of major joint or joint capsule with recording and 
reporting using ultrasound guidance. You say that you would like the plan to reconsider their denial. The Plan 
denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve aspiration and/or injection of major 
joint or joint capsule with recording and reporting using ultrasound guidance. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee does not have a diagnosis, condition, and/or symptoms that meet the Medicare 
criteria for coverage of aspiration and/or injection of major joint or joint capsule with recording and reporting 
using ultrasound guidance. There is a request for a 20611 procedure which is arthrocentesis, aspiration and/or 
injection, major joint or bursa (i.e. shoulder, hip, knee or subacromial bursa) with ultrasound guidance for 
diagnoses M25.551 and M25.552 which is for pain in the right hip and pain in the left hip. While the enrollee 
was noted to have pain on hip examination the documentation does not reveal objective evidence of hip 
osteoarthritis or pathology on hip x-rays per documentation. There are no other hip imaging records indicating 
a particular pathology of the hips. The enrollee recently had an epidural for an L5-S1 radiculopathy. L5 
radiculopathy can mimic hip pathology.  A review of the Faber test indicates that this test is nonspecific and 
therefore, not necessarily negative in the absence of intra-articular hip pathology. This hip provocation 
maneuver is a useful part of an evaluation that includes history, further examination findings, and other 
diagnostic studies. The documentation does not reveal failure of conservative management for the enrollee's hip 
pain with anti-inflammatory medications or physical therapy. The request does not specify what substance will 
be injected. The requested procedure of aspiration and/or injection of major joint or joint capsule with 
recording and reporting using ultrasound guidance is not considered the standard of care for the treatment of 
the enrollee's condition without a clear etiology of symptoms and failure of conservative care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of aspiration and/or injection of major joint or joint capsule with recording and 
reporting using ultrasound guidance have not been met. Therefore, we decided that the Plan does not have to 
pre-approve aspiration and/or injection of major joint or joint capsule with recording and reporting using 
ultrasound guidance.