Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for anterior left hip replacement for treatment of the enrollees hip pain. Findings:  The physician reviewer found that evidence-based, medical guidelines recommend total hip arthroplasty when all reasonable conservative measures have been exhausted and other reasonable surgical options have been seriously considered or implemented. Criteria include exercise therapy (supervised physical therapy and/or home rehabilitation exercises) and medications (unless contraindicated, non-steroidal anti-inflammatory drugs or steroid injection). Subjective findings should include limited range of motion, night-time joint pain, or no pain relief with conservative care. Objective findings should include over 50 years of age and body mass index less than 35. Imaging findings of osteoarthritis on standing x-rays or arthroscopy are required. Relative to the anterior hip replacement procedure, colleagues concluded that there was little evidence for improved kinematics or better long-term outcomes following the use of the direct anterior approach for total hip arthroplasty. The authors stated that well-designed, multicenter, prospective randomized controlled trials are required to provide evidence as to whether the direct anterior approach is better than the lateral or posterior approaches when undertaking total hip arthroplasty. Colleagues concluded that although direct anterior approach may provide shorter hospitalization and faster recovery during the early postoperative period, the available evidence is still insufficient to conclude whether the direct anterior approach or lateral approach is superior for total hip arthroplasty, and more high-quality studies and subsequent meta-analyses are needed. This patient presents with constant severe left hip pain with functional limitations in activities of daily living. Mechanical symptoms of frequent giving way, locking, and painful clicking are noted. Clinical examination findings are consistent with reported radiographic evidence of severe left hip osteoarthritis with joint space narrowing and bone spur formation. His body mass index is less than 35. Detailed evidence of long-term reasonable and/or comprehensive nonoperative treatment protocol trial and failure has been submitted. In general, evidence-based medical criteria have been met for hip replacement surgery. However, there is a lack of large volume, long-term, peer-reviewed outcome studies to support the use of anterior hip replacement surgery over standard hip replacement surgery at this time. Therefore, the requested anterior left hip replacement is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.