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

Physician 1: The patient is an active 51-year-old male with osteoarthritis who wishes to proceed with hip resurfacing arthroplasty.  His right hip has been the source of increasing pain over the past four years and his ability to participate in regular activities has been affected.  The Health Plan considers hip resurfacing an experimental/investigational procedure, and has denied authorization.There is currently mid-term follow-up data to support the use of hip resurfacing in relatively young patients who would otherwise require total hip replacement.  This patient is only 51 years old and appears to be very active.  He will most likely need a revision of the hip joint in his lifetime. Hip resurfacing will preserve his bone stock for a future revision procedure. He is a good candidate for the procedure.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 2: The patient is a 51-year-old male seeking authorization and coverage for a hip resurfacing procedure.  He has a history of osteoarthritis in the right hip, which has become more problematic over the last few years.  His specialist recommended the hip resurfacing procedure, but the Health Plan denied authorization based upon their determination that the procedure is experimental/investigational.There is currently insufficient scientific evidence supporting the hip resurfacing procedure as superior to more conventional hip replacement in terms of durability.  Resurfacing is associated with significant incidence of femoral loosening and is not particularly conservative in terms of acetabular bone removal. As such, the patient is likely to experience superior results from a standard treatment approach. 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 51-year-old male with end stage arthritis who was previously a very active person. He consulted with a specialist who recommended a hip resurfacing arthroplasty to relieve his pain. The Health Plan denied the procedure as being experimental/investigational for the treatment of osteoarthritis of the hip.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 implants is promoted as an alternative to total hip replacement for younger patients with osteoarthritis or avascular necrosis 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 primary total hip arthroplasty. Amstutz and Beaule, in the Journal of Bone and Joint Surgery, reported on a two to six year follow-up study of metal-on-metal surface replacement arthroplasties. 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 at 0.75%.In the case of this patient, he is a very active 51-year-old who most likely will need additional hip surgeries during his lifetime. Conventional total hip arthroplasty with metal-on-polyethylene (cross-linked polyethylene) has a track record of about 15 years and is very likely to last less than 10 years in young active patient. Given the promising early results of the hip resurfacing procedures, the requested procedure is medically reasonable and appropriate in this patient and should be authorized.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.