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

Physician 1: The patient is a 53-year-old male with arthritis of the left hip.  He has a great deal of pain, especially when walking, and has requested authorization and coverage for a left hip resurfacing procedure. The Health Plan denied authorization due to the experimental/investigational nature of the procedure.The requested procedure is an experimental/investigational procedure with very little data available on the newer metal-on-metal prostheses.  Hip resurfacing was abandoned in most centers in the 1970s and 1980s after dismal results were reported.  Although there has been a resurgence in interest with the metal on metal devices, there is still no long-term prospective study showing a benefit over conventional hip replacement.  All of the risks associated with the procedure are not known.  The device has recently been approved by the Food and Drug Administration with a 10-year stipulation pending further studies.  This procedure cannot be recommended as a superior option until it is proven effective, safe, and at least as good as conventional hip replacement.  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 53-year-old male with osteoarthritis of the left hip, which has progressed to the point that reconstructive surgery has been recommended. The patient has elected to undergo a metal-on-metal resurfacing hip arthroplasty. His physician has recommended this particular procedure due to his young age.  The Health Plan has denied coverage as they contend that metal-on-metal hip resurfacing arthroplasty has not been sufficiently evaluated in regard to efficacy and durability and is therefore an investigational procedure.Metal-on-metal hip resurfacing represents a promising alternative to traditional total hip arthroplasty for the treatment of hip osteoarthritis in young active patients. Short-term results have now been published. A report by Amstutz, et al. describes clinical and radiographic results of the first 400 hips treated with a metal-on-metal resurfacing prosthesis. The follow-up study spanned two to six years and comprised hips with an average follow-up of three and a half years. During the study period, 3% of the metal-on-metal arthroplasties were easily revised to an arthroplasty with a traditional stemmed component. This preliminary experience was viewed by the authors as encouraging. However, the Amstutz report indicates the procedure is at an investigational stage and concludes that continued close follow-up is needed to better define the results and indications for this procedure. The cautious appraisal of metal-on-metal hip resurfacing is further expressed in the recently published 8th Edition of Orthopaedic Knowledge Update from the American Academy of Orthopaedic Surgeons. The author summarizes the current status of bearing surfaces in total joint arthroplasty. His critique of the recent literature included the above-mentioned report. The author concluded that metal-on-metal hip resurfacing is in the investigational stage. In summary, the current literature supports the conclusion that although metal-on-metal hip resurfacing is promising, it is still investigational. At this point, there is no long-term data confirming the safety of high-level activity after metal-on-metal hip resurfacing. Thus, there is insufficient documented evidence to conclude that metal-on-metal hip resurfacing is superior to standard treatment modalities. Furthermore, in the case of this patient there is no clinical data indicating any emergent need for operative intervention. Accordingly, 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 53-year-old man with severe left hip arthritis. He has consulted with specialists, and has elected a left total hip resurfacing procedure as his procedure of choice to relieve his increasing pain. The Health Plan has determined the hip resurfacing procedure is investigational and has denied authorization.Hip resurfacing as an alternative to total hip replacement has been performed since the early 1970s. Initial experience was with 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 implants 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 fashion similar to a primary 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 data indicates 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 low at 7.5%.  Although this procedure appears promising, to date, there are no randomized, controlled clinical trials of metal-on-metal hip resurfacing comparing this procedure to a traditional total hip arthroplasty.  As such, there is insufficient evidence that the proposed procedure will be more efficacious for this patient than standard treatment modalities.As 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.