Runner with pain and NSAIDs

Patient: Young female runner. Two mos severe pain around IT origin. I’ll describe as partial tear at origin/iliac tubercle w mild tendinosis.

Treatment: non-steroidal anti-inflammatory drugs

Is Preauth Required? Non-steroidal anti-inflammatory drugs may be indicated for a young female runner with a partial tear at the origin or iliac tubercle with mild tendinosis. The treatment may be covered by Carelon Medical Benefits Management if the patient has received initial active instruction from a MD, DO, or PT with re-demonstration of their ability to perform exercises, as well as participation in a patient-specific or tailored program. Additionally, compliance must be documented or attested to by a clinician on a follow-up evaluation, and alternative therapies such as activity modification and/or a trial period of rest from the aggravating contributing factors must be utilized, where applicable.

Will the claim be denied? Non-steroidal anti-inflammatory drugs (NSAIDs) are generally used to treat tendinitis, so it is possible that the claim could be denied if the diagnosis is tendinosis instead of tendinitis.

When is the following treatment medically necessary for the condition specified? The treatment of non-steroidal anti-inflammatory drugs is considered medically necessary for a young female runner with severe pain around the origin of a tendon and a partial tear at the origin/iliac tubercle with mild tendinosis. This is because non-steroidal anti-inflammatory drugs can help reduce inflammation and pain, which can help the tendon heal and prevent further damage.