Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1: The patient is a 50-year-old male who has had approximately a one-year history of right hip pain. On exam he was found to have osteoarthritis with narrowing of the joint space and pistol grip deformity. Based on the patients history and current condition, the patients physician recommended the patient undergo a metal-on-metal resurfacing procedure. Authorization and coverage for the proposed procedure has been denied by the Health Plan on the basis it is considered investigational for treatment of the patients medical condition.The requested procedure is not the gold standard procedure for hip replacement as of this date. Previous surface replacements have been ineffective with high rates of failure and complications. At this time, metal-on-metal hip resurfacing has not been evaluated in terms of risk, benefit and complications, as well as long-term success of the prosthesis in question. Given the current results of the requested procedure, it is not likely to be more beneficial than standard total hip replacement.Based upon the information set forth above, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Physician 2: The patient is a 50-year-old male police who is physically very active. He has been diagnosed with advanced hip arthritis. The patient consulted an orthopedist who indicated the patient is a good candidate for metal-on-metal hip resurfacing. The Health Plan has denied coverage for the proposed procedure citing a lack of proven efficacy.Metal-on-metal hip resurfacing as an alternative to total hip replacement has been performed since the early 1970s. In the initial experience of metal against thin poly shells, the failure rate in short to mid-term cases became rather high and enthusiasm for the procedure lessened in the 1980s. However, there have been significant design improvements during the last decade. Currently, hip resurfacing with metal-on-metal implant is promoted as an alternative to total hip replacement for younger patients who would like to maintain a more active lifestyle. The procedure conserves acetabular bone stock, the femoral neck is not resected and the proximal femoral canal is not invaded. If at a later stage total hip replacement is necessary, a hip treated with resurfacing can be approached in a similar fashion as a primary total hip arthroplasty.There are currently no randomized, controlled clinical trials of metal-on-metal hip resurfacing comparing this procedure to a traditional total hip arthroplasty. Amstutz and Beaule in the Journal of Bone and Joint Surgery in January 2004 reported on a 2-6 year follow-up study of metal-on-metal surface replacement arthroplasties. The report includes 2.2 to 6.2 year follow-ups. The results indicate 400 hips were treated with this implant. The target group was younger and potentially physically active patients. Of the 400 hips, 3% were converted to total hip replacement at a later stage. Other complications included operations for component mismatch, removal of heterotopic bone, and re-operation for trochanteric bursitis. The dislocation rate was extremely low.Metal-on-metal hip resurfacing as an alternative to traditional total hip arthroplasty is currently promoted for use in younger, more active patients with osteoarthritis and/or avascular necrosis. Because of the patients young age and the likelihood for an additional revision procedure in the future, metal-on-metal hip resurfacing is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Physician 3: The patient is an active 50-year-old male with a greater than one-year history of progressive right hip pain secondary to radiographically confirmed osteoarthritis. A metal-on-metal resurfacing hip arthroplasty has been requested by the patient and recommended by his provider. The patients provider contends that metal-on-metal hip resurfacing would be superior to a traditional stemmed total hip arthroplasty given the patients young age and his apparent desire to pursue high-level activities. The Health Plan has determined metal-on-metal hip resurfacing is currently considered investigational and therefore, has denied authorization for the procedure.Metal-on-metal hip resurfacing represents a promising alternative to traditional total hip arthroplasty for the treatment of hip osteoarthritis in young patients. Short-term results have now been published. A report by Amstutz, et al. describes clinical and radiographic results of the first 400 hips treated with a metal-on-metal resurfacing prosthesis. The follow-up study spanned two to six years and comprised hips with an average follow-up of three and a half years. During the study period, 3% of the metal-on-metal arthroplasties were easily revised to an arthroplasty with a traditional stemmed component. This preliminary experience was viewed by the authors as encouraging. However, the Amstutz, et al. report indicates the procedure is at an investigational stage and concludes that continued close follow-up is needed to better define the results and indications for this procedure. The cautious appraisal of metal-on-metal hip resurfacing is further expressed in the recently published 8th Edition of Orthopaedic Knowledge Update from the American Academy of Orthopaedic Surgeons. The author summarizes the current status of bearing surfaces in total joint arthroplasty. His critique of the recent literature included the above-mentioned report. The author concluded that metal-on-metal hip resurfacing is in the investigational stage. The current literature supports the conclusion that although metal-on-metal hip resurfacing is promising, it is still investigational. At this point, there is no long-term data confirming the safety of high-level activity after metal-on-metal hip resurfacing. Thus, at this point there is theoretical support, but insufficient documented evidence to conclude metal-on-metal hip resurfacing is superior to standard treatment modalities. Furthermore, in the case of this patient, there is no clinical data indicating any emergent need for operative intervention. Accordingly, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.