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

Physician #1:  The patient is a 45-year-old man with severe osteoarthritis of the hip. He has requested authorization and coverage for hip resurfacing arthroplasty. The Health Plan has denied this request indicating that the requested procedure is considered experimental for treatment of the patients medical condition. The requested procedure remains unproven at this time. There are no long-term, prospective studies demonstrating its efficacy or outlining its risks. In fact, hip resurfacing arthroplasty is generally out of favor given the extremely poor results of the technique. The patient is likely to achieve superior results with standard treatment modalities. 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 45-year-old male. He has disabling hip arthritis. His provider believes he is a strong candidate for a hip resurfacing procedure. The Health Plan has denied coverage for the procedure citing a lack of proven efficacy in this clinical setting.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.Hip resurfacing arthroplasty is an alternative to traditional total joint arthroplasty and is currently promoted to be indicated in younger, more active patients with osteoarthritis such as this patient. Given the severity of the patients condition and his very young age, hip resurfacing arthroplasty is a medically reasonable and appropriate treatment option. Accordingly, I have determined that the requested procedure 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 a 45-year-old man with severe osteoarthritis of the hip. He has requested authorization and coverage for hip resurfacing arthroplasty. The Health Plan has denied this request indicating that the requested procedure is considered experimental for treatment of the patients medical condition. The Health Plans denial should be upheld. There is no long-term data to establish the efficacy of hip resurfacing arthroplasty. There is a risk of significant complications including fracture and avascular necrosis with the procedure. Given that long-term outcomes remain unknown the procedure cannot be recommended at this time. 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. Therefore, the Health Plans denial should be upheld.