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

Physician 1:  The patient is a 53-year-old man with hip arthritis. He and his provider have requested authorization for hip resurfacing arthroplasty. The Health Plan considers this procedure experimental/investigational and therefore has denied the request for authorization.Hip resurfacing is not currently the standard of care for severe osteoarthritis, as there is not sufficient peer-reviewed data establishing the long-term efficacy and durability of the procedure. There is no evidence to suggest that hip resurfacing is a better or more effective procedure than conventional total hip replacement. 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. The Health Plans denial should be upheld.Physician 2:  The patient is an active 53-year-old male with painful moderately severe arthritis of the right hip and moderately degenerative arthritis of the left hip. He has requested a right hip resurfacing arthroplasty with a metal-on-metal device, which has been denied by the Health Plan on the basis that there is insufficient evidence in the peer-reviewed medical literature to conclude the procedure is comparable or superior to the standard of care procedure: total hip replacement. At issue is whether the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.The patient has reviewed the surgical options and appears well educated on the subject. In view of the patients age and activity level, hip resurfacing does appear to offer added benefits. The implant is more wear resistant and less likely to dislocate. The procedure also preserves more femoral and acetabular bone stock so that revision to a conventional total hip replacement can be accomplished, if necessary.Based upon the information set forth above, I have determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 3:  The patient is a 53-year-old male with severe painful arthritis of the hip.  He has tried conservative treatment modalities without sustained benefit. The patient has submitted a request for hip resurfacing arthroplasty to his Health Plan.  The Health Plan considers this an investigational procedure and has denied authorization.The efficacy of the procedure in question remains unproven. There are no long-term prospective studies that show there is clear benefit over traditional hip replacement procedures and the extent of the related risks is still unknown.  Until studies have been published that demonstrate effectiveness, benefit, and long-term success of the hip surface replacement procedure, it cannot be recommended over conventional treatment.  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.