Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

The patient is a 46-year-old female with an onset of left hip, groin, and flank pain in spring 2016. She was diagnosed with a kidney stone and underwent removal with residual left hip/groin pain. She additionally underwent a gynecological and gastrointestinal work-ups. It was determined that she had a musculoskeletal problem causing the left hip/groin pain. She was referred to physical therapy and completed two months of therapy without resolution of symptoms. The 12/28/16 left hip magnetic resonance imaging with and without contrast impression documented a complex tear of the anterior left acetabular labrum, involving virtually the full thickness of the labral base. There was a reactive subcortical cyst in the proximal left femur at the anterolateral femoral head-neck junction, which could be the sequela of femoroacetabular impingement. The 1/3/17 orthopedic report cited complaints of left sided groin pain for over a year, and a fair amount of flank pain. She had tried Advil and Tylenol with little relief of her pain. Physical examination showed a positive impingement sign. There was no palpation tenderness in the bilateral groins, no right hip pain, no palpable trochanteric bursal tenderness, and no sciatic notch tenderness. The diagnosis was symptomatic left acetabular labral tear. The treatment plan recommended a fluoroscopically guided intraarticular injection to assess pain relief and symptoms generated from the labral tear. The 1/4/17 second opinion orthopedic report indicated a recommendation for an intraarticular injection of the left hip for diagnostic purposes. It was noted that if she obtained significant relief from the injection, then a hip scope would be considered. The 1/4/17 procedure note indicated that a fluoroscopically guided intraarticular left hip corticosteroid injection was performed. It was noted that her physical therapy had included activities for hip range of motion, hip strengthening and overall gait activities without a reduction in her hip/groin symptoms. Additional physical therapy for the left hip was not recommended. The 1/11/17 orthopedic report cited on going left hip pain that was worse with sitting, standing, climbing stairs, and all activity. She had experienced night pain but no instability. Most of the pain localized to the C sign area, with the pain extending into the abdomen and left lower lumbar region. Radiographs and imaging were reviewed and showed a complex labral tear and cam impingement. The diagnosis was left hip labral degenerative tear, and hip impingement syndrome. Even though she had an atypical pain pattern, because she had full improvement of all of her symptoms with the injection, a hip scope was recommended. The 1/31/17 operative report documented a diagnosis of left hip degenerative labral tearing and pincer type impingement. She had an intraarticular corticosteroid injection which relieved her symptoms dramatically temporarily. A diagnostic hip arthroscopy had been recommended based on her response to the injection and her magnetic resonance imaging findings of a complex labral tear along with possible Cam-type impingement. It was noted that she had atypical pain pattern, specifically the orthopedic surgeon did not think her flank pain would be affected by a labral tear. Operative examination confirmed a pincer lesion and mild degenerative joint changes of the left hip. The surgical procedure was documented as left hip arthroscopic pincer lesion resection and labral debridement. The patient has requested reimbursement for reimbursement for hip surgery performed on 1/31/17. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of this patients medical condition. Current peer reviewed literature support surgical management of femoroacetabular impingement syndrome when nonsurgical treatment methods fail. In this case, the patient presented with an approximate one year history of left hip, groin and flank pain. She had been diagnosed with kidney stones and underwent removal without resolution of the hip/groin pain. The patient additionally underwent gynecological and gastrointestinal workups without significant findings. She continued to report persistent pain interfering with her work duties and activities of daily living, and interrupted her sleep. She was referred for left hip MRI and orthopedic consult. Clinical examination findings were consistent with radiographic and imaging evidence of a left hip complex labral tear and impingement syndrome. She failed over six months of conservative treatment including activity modification, analgesics, anti-inflammatory medications, and physical therapy. She underwent a diagnostic intra-articular left hip injection with complete temporary resolution of her symptoms. X-ray findings documented no signs of joint space narrowing, and no erosive or prolific arthritic changes. She underwent left hip arthroscopic pincer lesion resection and labral debridement on 1/31/17. Operative findings confirmed the presence of a pincer lesion. Therefore, the hip surgery performed on 1/31/17 was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.