Diagnosis: Right hip pain
Treatment: hip magnetic resonance imaging (MRI) (right)
The insurer denied coverage for hip magnetic resonance imaging (MRI) (right)
The denial is overturned.

This is an adult with a history of bilateral hip pain and fibromyalgia. The patient presented to the Orthopedist's office for hip pain. The patient tried and failed physical therapy (PT). An x-ray of the hips revealed no significant findings. The physician requested coverage for magnetic resonance imaging (MRI) of the hip.

The medical records show difficulty in defining the pain generator. Several diagnoses have been proposed over years. The important factors are there is evidence of hip pain. It has been reported to the lateral and groin area. There is documentation of functional loss. Courses of PT have been provided. Physical examination was remarkable for limited motion. X rays did not show any specific abnormality. A differential diagnosis included possible labra tear. There should be consideration for stress fracture as well. Advanced imaging would be beneficial in obtaining additional information. Treatment recommendations would depend upon the special studies. The MRI/arthrogram would thus be necessary at this time.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for hip magnetic resonance imaging (MRI) (right) is substantiated.