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

Physician 1: The patient is a 38-year-old female with a long-standing history of hip pain. She has been diagnosed with osteoarthritis. The patients physician recommended metal-on-metal hip surfacing, which the Health Plan has denied due to a lack of scientific evidence in peer-reviewed medical literature to support its efficacy.Metal-on-metal hip resurfacing is still in experimental/investigational studies. Short-term data is sparse, with no long-term prospective study establishing its effectiveness. In addition, the procedures risks are uncertain. Furthermore, there are other treatments available for this patient. At this time, metal-on-metal hip resurfacing cannot be recommended as there is very little data to warrant its general use. 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 2: The patient is a 38-year-old female with a long-standing history of pain in her left hip. The patient has undergone two arthroscopic procedures without sustained relief. The patients physician recommended metal-on-metal hip surfacing. The Health Plan has denied this request indicating the efficacy of metal-on-metal hip resurfacing has not been established in peer-reviewed literature.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 is an alternative to traditional total hip arthroplasty and it is currently promoted to be indicated in younger, more active patients with osteoarthritis and/or avascular necrosis. The procedure is performed under a FDA study and is considered investigational. In the case of this patient, she has what appears to be mild to moderate osteoarthrosis without evidence of avascular necrosis. The submitted examination notes are not consistent with severe arthritis. Furthermore, there is no evidence that metal-on-metal hip resurfacing is likely to be more beneficial than traditional 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.Physician 3: The patient is a 38-year-old female with a four-year history of avascular necrosis. By x-ray, she has mild osteoarthritis, which is confirmed with MRI. The patients provider noted the patient had gait antalgia and severe pain. The patients provider feels that although her findings were mild on diagnostic studies she may obtain some benefit from metal-on-metal hip resurfacing. The Health Plan has denied authorization and coverage for the proposed procedure.While the logic behind metal-on-metal total hip resurfacing is good, the efficacy of this procedure has not been demonstrated. More long-term follow up and comparison to other types of hip replacements will help determine if metal-on-metal resurfacing is of greater or similar efficacy than traditional hip replacements. To date, there is insufficient evidence that metal-on-metal resurfacing will avoid the need for early revision. Furthermore, based upon the information provided, it is not clear the patient warrants 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.