Hip Pain and Suspected Labral Tear, FAI or Ischiofemoral Impingement

Diagnostic Test Appropriate Use Rules

1. Hip radiographs should be performed before MRI (ideally with modified Dunn)
2. MRI is highly effective for diagnosing ischiofemoral impingement
3. MRA is highly effective for diagnosing labral pathology and cartilage lesion
4. Imaging with 3T MR is better than 1.5T MR for evaluating labral and chondral pathology
5. Consider diagnostic injection for suspected FAI, especially for low sensitivity, low prevalence situations
6. Diagnostic arthroscopy may still have a role in the absence of MRI diagnosis for hip pathology 

MRI Medical Necessity Rules

In addition to having groin or buttock pain, patients must be <50 years of age and have two of the following indicators:

Radiographic indicators

1. Absence of joint space narrowing
2. Cam or pincer
3. Crossover sign or ischial spine sign
4. Os acetabulae

Clinical indicators

1. Pain at the end of hip range of motion
2. Reproducible groin pain on hip flexion/adduction/internal rotation
3. “Positive” response to intra-articular injection
4. Prior hip arthroscopy or open hip procedure

MRI Appropriate Use Criteria for Labral Tear

Recent X-ray and at least two of the following:

• Hip or groin pain
• Giving way by history
• Clicking
• Pain with ROM
• Limited ROM

If above criteria are met, order: MRI WO Contrast (Left versus Right versus Bilateral)

MRI Appropriate Use Criteria for Femoroacetabular Impingement

Nondiagnostic x-ray and at least two of the following:

• Hip or groin pain
• Giving way by history
• Clicking
• Pain with ROM
• Limited ROM
• Positive impingement test

If above criteria are met, order: MRI WO Contrast (Left versus Right versus Bilateral)

Shoulder Pain & Suspected Rotator Cuff Tear or SLAP Lesion

Diagnostic Test Appropriate Use Rules

1. Radiographs should be performed as the initial imaging test for shoulder pain. A range of conditions can be identified and subsequently treated (e.g., calcific tendinosis).

2. For suspected rotator cuff tears, US and MRI are equivalent. Although US is less expensive, it is highly operator dependent.

3. MRI is superior for looking at intra-articular pathology, such as labral tears.

4. MRI and MRA are similar in efficacy, but a few studies suggest higher sensitivity and specificity in identifying intra-articular pathology with MRA, such as labral tear.

MRI Medical Necessity Rules

In addition to pain, patients must have two of the following clinical indicators:

1. Traumatic event by history or overuse syndrome (e.g., pitcher)
2. History of limited function or described weakness
3. Physical exam finding of shoulder tenderness
4. Painful or limited motion
5. Weakness on muscle testing
6. Clicking or popping perceived by patient or on physical exam during rotation or shoulder elevation
7. Pain with manual shoulder elevation

This guide is for informational purposes only and does not constitute medical or legal advice, and is not intended for use in the diagnosis or treatment of individual conditions. The guide is not comprehensive and is provided as an example only, and should not be used as a substitute for the exercise of professional judgment, including but not limited to, in connection with any billing, imaging, CPT or other orders or healthcare claims related matter. The mention of any test, protocol, product, service, organization, activity, or therapy should not be construed as an endorsement by Johns Hopkins or its affiliates. This information is provided without representations or warranties of any kind, express or implied, all of which are disclaimed. Johns Hopkins and its affiliates assume no responsibility for any injury or damage to persons or property, delays or loss of revenue/income arising out of or related to the guide.