Hip Pain 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 computerized tomography (CT) scan with contrast of the bilateral hips and/or magnetic resonance imaging (MRI) scan with contrast of the bilateral hips. According to the American College of Radiology (ACR) recommendations for the evaluation of chronic hip pain in a patient when a non-infectious, extra-articular abnormality such as tendonitis, or bursitis is suspected and radiographs are negative, then an MRI of the hip is considered usually appropriate. MRI can evaluate the soft tissue structures surrounding the hip joint which may be causing the patient’s pain such as bursitis, tendinosis, or tendonitis. The sacroiliac (SI) joints may also be visualized in the field of view and may also be a source of pathology.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a magnetic resonance imaging (MRI) of the lower extremity for evaluation of the enrollee’s left hip pain. Findings: Two physician reviewers found that the patient is currently a long distance runner, averaging up to 75 miles per week. As noted in the medical literature, runners experience a myriad of orthopedic problems including simple arthritis, acetabular labral tears, stress fractures, avascular necrosis, bursitis of the iliotibial band, tendinopathy/bursitis, piriformis syndromes, and hernias. The American College of Radiology (ACR) noted that in this clinical setting, a patient should have routine plain x-rays.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Vicodin 5 mg to be taken twice daily. On determining when to initiate or continue opioids for chronic pain, Dowell and colleagues report, “Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.” The guidelines further advise, “Clinicians should evaluate benefits and harms with patients within one to four weeks of starting opioid therapy for chronic pain or of dose escalation.

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for hyaluronan/derivative Euflexxa IA injection per dose for treatment of the enrollee’s hip pain. Findings: The physician reviewer found that The submitted documentation fails to demonstrate the medical necessity of the requested services. Piccirilli and colleagues performed a systematic review and meta-analysis regarding hyaluronic acid (HA) injections in hip disorders. The authors concluded that there is a lack of standardization of HA injections for hip conditions. Their results suggested that this is the best conservative therapy before surgery and it can act on pain relief and function. However, the authors noted “there is no evidence to prove its ability to modify the morphological structure of the pathological hip and the natural history of the disease.

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 hip pain, then check the rights and deadlines that apply to your plan.