Femoroacetabular Impingement denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hip arthroscopy with labral repair, acetabuloplasty and femoroplasty. Findings: The physician reviewer found that femoroacetabular impingement results from bony morphologic abnormalities of the hip joint that result in abnormal contact during motion. Patients with femoroacetabular impingement present with chronic, deep, or aching anterior groin pain most commonly in the sitting position, or during or after activity. Patients might also experience occasional sharp pains during activity. Diagnosis of femoroacetabular impingement should be confirmed with radiography. Femoroacetabular impingement can be managed conservatively with rest, modification of activities, medications, and physiotherapy, or with surgical intervention.

An enrollee has requested reimbursement for hip arthroscopy with femoroplasty. This patient presented with a history of right hip pain. On physical examination, the patient’s pain was associated with tenderness and some restriction of motion, particularly abduction and internal rotation. X-rays revealed 1 mm narrowing of the right hip joint space compared to the left. Magnetic resonance arthrogram demonstrated hypertrophic labrum, subchondral cyst formation in the acetabulum, and denting of the head and neck junction, indicating cam and pincer impingement. The patient underwent a complex right hip arthroscopy. Femoroacetabular impingement is a clinical syndrome, characterized by abnormal cam or pincer type morphology in the hip that alters the biomechanical, forces causing rapid progression of osteoarthritis and chondral and labral tearing.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for right hip arthroscopy with femoroplasty and hip arthroscopy with labral repair. Researchers report, “Labral tear is generally secondary to femoroacetabular impingement, trauma, dysplasia, capsular laxity, and degeneration. Patients with labral tear complain about anterior hip or groin pain most commonly with a most consistent physical examination called positive anterior hip impingement test. Magnetic resonance arthrography is a reliable radiographic examination with arthroscopy being the gold standard. Conservative treatment consists of rest, non-steroidal anti-inflammatory medication, pain medications, modification of activities, physical therapy, and intra-articular injection.

Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for the left hip arthroplasty procedure, or in the alternative, surgical procedure to shave the left femoral head and/or repair the left hip labral tear.Medical literature currently indicates that a total hip arthroplasty (THA) is indicated in end-stage hip osteoarthritis with a high degree of persistent pain when conservative treatment has failed the patient. This statement is valid for patients where the medical history, clinical examination, and radiographic findings are conclusive.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving femoroacetabular impingement, then check the rights and deadlines that apply to your plan.