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Female 40s - known psoriasis

Patient: Female 40s - known psoriasis Bilateral lateral hip, groin, gluteal pain - spontaneous onset possibly after viral illness Am stiffness ++, improves with exercise & NSAIDs Now L knee pain, warmth, effusion MRI - symmetrical gluteal, iliopsoas, adductor & proximal hamstring enthesopathies US - knee synovitis ++ Interesting / atypical pattern for psoriatic spondyloarthritis



Female 40s - known psoriasis

What is prior authorization justification?


The prior authorization justification for the treatment and condition of a female in her 40s with known psoriasis, bilateral lateral hip, groin, and gluteal pain, stiffness that improves with exercise and NSAIDs, and now pain and warmth in the left knee with effusion and MRI and US evidence of enthesopathies, is that the patient has inflammation of the spine and joints that is consistent with psoriatic spondyloarthritis and is not responding to conservative treatments.


When is the treatment medially necessary for the condition?


Hip arthroscopy is considered medically necessary for treatment of FAIS when all of the following criteria are met: moderate to severe hip pain primarily in the groin and worsened by flexion activities; interference with activities of daily living that is not explained by another diagnosis; positive impingement sign on clinical examination; imaging studies suggesting a diagnosis of FAIS including cam impingement and/or pincer impingement; pistol grip deformity; femoral head neck offset with an alpha angle greater than 50 degrees; positive posterior wall sign; acetabular retroversion; coxa profunda or protrusion; and damage of the acetabular rim.

For the knee, lateral retinacular release is considered medically necessary when all of the following criteria are met: positive lateral patellar tilt established on imaging; failure of at least 6 months of conservative management; radiographic imaging consistent with Kellgren Lawrence grade 2 or lower patellofemoral osteoarthritis; and at least one of the following is present: positive patella glide test, positive patella tilt test, lateral femoral trochlear or lateral patella facet cartilage lesion confirmed by imaging within the past 12 months, when symptoms are consistent with a cartilage defect.






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