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

Patient with a past medical history of morbid obesity with osteoarthritis of the right hip, and severe obesity with BMI 50-50.9 requesting coverage for total right hip replacement surgery. The insurer denied coverage for right total hip replacement surgery as not medically necessary.  The recommended approach to treatment was to begin a formal diet program to assist with necessary weight loss. The patient was evaluated for hip pain with walking and with hip flexion.  MRI showed some cartilage loss and mild hip osteoarthritis on x-rays. Body Mass Index (BMI) was 52, and physical exam was consistent with arthritis of the right hip.  Per report, x-rays at that visit showed progression of hip arthritis. Patient was referred to orthopaedics for evaluation and treatment of arthritis of hip. Treatment also included a hip injection of steroids, which was repeated one time with relief.  Patient walks with a walker due to the pain in hip, especially as the injections wear off. Weight loss was recommended to safely proceed with hip replacement. Attendance at a formal weight loss program was recommended due to the risks of hip replacement in the morbidly obese.  They reportedly discussed different treatment options for hip pain, including pain medications and the risk of continued injections. An additional opinion was sought and agreed that surgery would be high risk due to weight, and that patient would be at additional risk for significant medical or surgical complications.   Finally, this provider agreed to reconsider hip surgery if patient lost 25 pounds. Review of Medical LiteratureWhile the treatment of arthritis and obesity is complicated, the literature does support the use of arthroplasty (surgical reconstruction or replacement of a joint) as a pain relieving procedure that is effective in reducing pain and improving quality of life.  From a general outcome standpoint, it is known that improvements in pain and function are gained after hip replacement in obese and morbidly obese patients. Studies have shown both supportive and discouraging results on surgical treatment of terminal arthritis with total knee arthroplasty and total hip arthroplasty for obese patientsCentral to determining the need for an elective procedure is assessing the risk of the procedure itself in a specific patient population. A high body mass index (BMI) is associated with significant complications in patients undergoing total joint arthroplasty. In a recent study published using the National Surgical Quality Improvement Program database from 2008-2015, patients were arranged into 3 groups based on BMI: O1 (BMI 30-34.9 kg/m2), O2 (BMI 35-39.9 kg/m2), and O3 (BMI >40 kg/m2). Thirty-day complications were recorded and evaluated utilizing univariate and multivariate analyses stratified by BMI.  The study found that patients with a BMI >40 kg/m2  had longer operating times, length of stay, higher rates of readmissions, re-operations, deep venous thrombosis, renal insufficiency, superficial infections, deep infections, and wound dehiscence. In a similar study found that there was a marked increase in medical and surgical complications in patients with a BMI over 45 undergoing hip arthroplasty. Given the pre-operative pain that patients have at the time of surgery, patients often feel that a joint replacement will improve outcomes and allow them to exercise after joint replacement.  However, this has been found to not be true.  Ast, et al found that a majority of patients, 73%, that underwent hip replacement did not change body mass index.  Jones, et al found that severe obesity was a significant risk factor for worse pain and functional recovery at 6 months compared to patients that are not obese. At this point in time, many arthroplasty centers have body mass index cut offs where there is a weight loss program to encourage weight loss and decrease complications prior to joint replacement.  While individual surgeons vary, the general accepted BMI cut offs are at 40 or 35, as both have been shown to be predictors of higher short term complication rates.  For example, one leading joint replacement center, has a BMI cut off of 40. In this case, multiple providers offered continued non-operative management. While the request for a hip replacement is reasonable, the review of current practices and literature suggests that weight loss prior to hip replacement at this time is prudent and clearly is in the patients best interest to decrease the risk of a peri-operative or post-operative complication that would lead to worse overall function.  This reviewer agrees with the decision to deny the hip replacement in lieu of a weight loss program prior to joint replacement hopefully in the near future.Right hip surgery is not medically necessary at this time. The denial of coverage and authorization should be upheld.