Labral Tear 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.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested reimbursement for a magnetic resonance imaging (MRI) of the right hip.Per the American College of Radiology (ACR) guidelines, the requested magnetic resonance imaging (MRI) of the right hip is medically necessary for further evaluation of this patient. The ACR guidelines reveal that MRI is currently the reference standard for the evaluation of labral pathology. Further, the ACR guidelines indicate that for the evaluation of chronic hip pain with suspected labral tear and negative radiographs, an MRI is considered appropriate.

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.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for right hip arthroscopy with labral surgery. Regarding the diagnosis and treatment of labral tear, 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.

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 labral tear, then check the rights and deadlines that apply to your plan.