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

Physician 1:  The patient is a 61-year-old male requesting metal-on-metal hip resurfacing arthroplasty for end stage osteoarthritis of the left hip rather than conventional total hip arthroplasty due to an extremely physically active lifestyle. The Health Plan has denied authorization for the requested procedure as experimental and investigational.The orthopedic surgeon who examined the patient considers him to be an excellent candidate for resurfacing, which he states combines the wear resistance of metal-on-metal with bone conservation thereby allowing nearly normal motion and stress transfer and good joint stabilization. By preserving proximal femoral bone, reconstructive options are maintained if additional surgery or revision becomes necessary. Considering the currently available data, the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 2:  The patient is a 61-year-old man with end-stage osteoarthritis of the left hip. He consulted a provider who recommended metal-on-metal hip resurfacing arthroplasty. The Health Plan considers this procedure investigational and therefore has denied coverage.The efficacy of the procedure in question remains unproven.  There are no long-term prospective studies that show there is clear benefit over traditional hip replacement procedures and the extent of the related risks is still unknown.  Until studies have been published that demonstrate effectiveness, benefit, and long-term success of metal-on-metal hip resurfacing arthroplasty, it cannot be recommended over conventional treatment.  Therefore, 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.Physician 3:  The patient is a 61-year-old man with severe hip arthritis. He has consulted two orthopedists prior to his visit with the orthopedic surgeon. His surgeon recommends metal-on-metal total hip arthroplasty, authorization for which has been denied by the Health Plan.Hip resurfacing as an alternative to total hip replacement has been performed since the early 70s with published reports in 1978.  In the initial experience with metal against thin poly shells, the failure rate in short to mid-term cases was high and enthusiasm for the procedure lessened in the 80s.  Work has continued with metal-on-metal resurfacing procedures and the design has improved significantly over 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 that has been treated with resurfacing can be approached in a manner similar to a primary total hip arthroplasty.There are as yet no randomized controlled clinical trials of metal-on-metal hip resurfacing arthroplasty comparing this procedure to a traditional total hip arthroplasty.  Amstutz and Beaule in the Journal of Bone and Joint Surgery in January 2004, report on a two to six-year follow-up study of surface replacement arthroplasties. 400 hips were treated with this implant. The target group was younger and physically potentially active patients. Of the 400 hips, 3% were converted to total hip replacements with other complications including component mismatch, heterotopic bone growth, and trochanteric bursitis. The dislocation rate was 0.75 percentSurface replacement arthroplasty (metal-on-metal) is an alternative to traditional total joint arthroplasty and it is currently promoted to be indicated in younger, more active patients with osteoarthritis and/or avascular necrosis. The patients age is at the very upper age band of potential benefits with surface replacement arthroplasties. One of the major indications for surface replacement versus conventional arthroplasty is the indication for patients who might need additional surgeries during their lifetimes. Currently, conventional total hip arthroplasties in patients over the age of 60 have an excellent track record and it is very unlikely that the patient will be in need of additional hip surgery during his lifetime.With all of the above in mind, I have determined 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.