Hip Problem Pain: when insurers say no, reviewers often say yes

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for radiofrequency ablation with Coolief technology and monitored anesthesia care (MAC). Sacroiliac joint dysfunction (SIJ) is a very common cause of refractory lower back pain commonly felt in the gluteal region but may also affect the lower extremities and/or the lumbar region. In a study, the authors evaluated radiofrequency ablation (RFA) of the sacroiliac joint (SI) joint and found that all patients who underwent RFA reported excellent pain relief and ceased taking analgesic medications.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for right sacroiliac (SI) joint fusion surgery (CPT 27279). The International Society for Advancement of Spine Surgery (ISASS) provided criteria for sacroiliac (SI) joint fusion (Lorio, et al.). The requirements include significant SI joint pain confirmed by at least three positive SI joint provocative tests, confirmation of the SI joint as a pain generator with at least 75% decrease in pain following fluoroscopically guided diagnostic intra-articular SI joint block in the immediate post-injection period, and failure to respond to at least six months of non-surgical treatment. The ISASS noted that additional or alternative diagnoses that could be responsible for the patient’s ongoing pain or disability should be evaluated and ruled-out.

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.

Patient with a past medical history of morbid obesity with osteoarthritis of the right hip, and severe obesity with BMI 50-50.9 requesting coverage for total right hip replacement surgery. The insurer denied coverage for right total hip replacement surgery as not medically necessary. The recommended approach to treatment was to begin a formal diet program to assist with necessary weight loss. The patient was evaluated for hip pain with walking and with hip flexion. MRI showed some cartilage loss and mild hip osteoarthritis on x-rays. Body Mass Index (BMI) was 52, and physical exam was consistent with arthritis of the right hip. Per report, x-rays at that visit showed progression of hip arthritis. Patient was referred to orthopaedics for evaluation and treatment of arthritis of hip. Treatment also included a hip injection of steroids, which was repeated one time with relief.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for hip problem pain was denied, the published record says the denial is worth fighting.