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

Physician 1: The patient is a 55-year old woman with severe painful arthritis of the left hip.  She has researched alternatives to total hip replacement and has submitted a request for hip surface arthroplasty to her Health Plan.  The Health Plan considers this an investigational procedure and has denied authorization.The efficacy of the procedure in question remains unproven.  Very little data is available to support the use of this procedure for the general population.  There are no long-term prospective studies that show there is any benefit over traditional hip replacement procedures and the extent of the related risks is still not clear.  Previous attempts at resurfacing the hip led to abandonment of the procedure in the United States.  Until studies have been published that demonstrate effectiveness, benefit, and long-term success of the surface replacement procedure, it cannot be recommended over conventional treatment.  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. The Health Plans denial should be upheld.Physician 2: The patient is a 55-year-old female with osteoarthritis of the left hip. She has experienced worsening pain over the past year. The patient has consulted a provider who recommends left hip resurfacing arthroplasty as an alternative to total hip replacement. The Health Plan denied coverage for the proposed procedure because they consider it an investigational treatment of the patients condition.Total hip resurfacing arthroplasty is not currently the standard of care for severe osteoarthritis, as there is not sufficient peer-reviewed data establishing the long-term efficacy of the procedure. Given the patients age, there is no evidence to suggest that hip resurfacing is a better or more effective procedure than conventional total hip arthroplasty. In comparing the surgical options, total hip replacement remains the standard of care for treatment of severe hip joint disease.  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. As such, the Health Plans denial should be upheld.Physician 3: The patient is a 55-year old woman with severe arthritis of the hip.  She is in need of surgical intervention due to intractable pain.  A request has been made for hip surface arthroplasty. The Health Plan has denied authorization for the procedure indicating that hip resurfacing is experimental/investigational and has not been sufficiently evaluated with regard to long-term outcomes.  The Health Plan is correct that hip resurfacing arthroplasty remains an experimental/ investigational procedure without established long-term clinical efficacy.  Previous attempts at resurfacing in the 1970's and 1980's were failures and the procedure was subsequently abandoned.  Recently, interest in the procedure has been renewed and new studies are underway that suggest the possibility of more promising outcomes.  Still, there are currently no long-term, prospective studies that demonstrate a clear benefit with the resurfacing procedure over the conventional approach of total hip replacement.  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.