Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic injuries.
Treatment: Total hip arthroplasty (code 27130).

The insurer denied coverage for the total hip arthroplasty (code 27130).  The denial is upheld. 

This is a female patient with a history of a slip and fall.  The patient had multiple orthopedic injuries, including multiple spine surgeries.  The patient presented to the orthopedic surgeon with complaints of left hip pain that had not improved with non-surgical management.  A magnetic resonance imaging (MRI) revealed a labral tear.  The patient underwent a left hip arthroscopic surgery to repair the tear.  However, after 3 months of post-operative rehabilitation, the patient's condition had not improved, and she continued to have hip pain.  The patient reported that she continued to ambulate with an antalgic gait, and she was unable to fully participate in physical therapy because of the left hip pain.  The patient was also unable to flex her left hip without assistance.  The patient took Percocet and Lyrica daily with mild relief.  A diagnostic hip injection confirmed that the intra-articular joint was the source of this patient's pain.  The orthopedic surgeon recommended a left anterior hip replacement with robotic technology due to the continuous hip joint related pain that has not improved with conservative management and arthroscopic surgery. 

The indications for surgery require identification of the pain generator and likelihood improvement will result with operative intervention.  There should be consistency of subjective complaints, objective findings on physical examination, imaging studies and a diagnosis.  The whole person's clinical condition should be taken into consideration including medical comorbidities and psychological aspects.  These factors will also have an effect on response to management. 

Based on the review of the medical record, the clinical facts do not provide clear identification of the source of this patient's pain.  The history of previous back surgery (i.e., reported multiple spine surgeries) does not discount the lumbar area as source of pain.  Also, the recent history reports knee clicking and pain.  Thus, it is unclear whether the patient's pain is originating from the hip or rather the back or the knee.  This identification is especially important considering that this patient had no clinical improvement from the hip procedure, and does not have any imaging study demonstrating evidence of a degenerative joint disease.  The report of "intraoperative full chondral defect and advanced osteoarthritis" does not have credence as a surgical indicator.  The Tonnis stage is without abnormality.  There is no joint space narrowing. The patient has undergone several procedures and injections to multiple body parts without improvement.  Thus, it is unlikely that additional surgery will provide clinical benefit to this patient at this time. 

Total hip arthroplasty (code 27130) is not considered medically necessary for this patient.

The health plan acted reasonably with sound medical judgment and in the best interest of the patient.

The carrier's denial of coverage for total hip arthroplasty (code 27130) should be upheld.  The medical necessity is not substantiated.