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

Physician 1: The patient is a 56-year-old male with osteoarthritis of the right hip. He has attempted conservative therapy without sustained relief. The patient has consulted a provider who has recommended right total hip resurfacing arthroplasty. The Health Plan has denied coverage for the proposed procedure on the basis it is considered investigational for treatment of the patients condition.Total hip resurfacing arthroplasty is not currently the standard of care for severe osteoarthritis as there is not sufficient peer-reviewed data establishing the long-term efficacy of the procedure. Given the patients age, he is an appropriate candidate for conventional total hip replacement. There is no evidence hip resurfacing arthroplasty will be more effective for this patient than 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. As such, the Health Plans denial should be upheld.Physician 2: The patient is a 56-year-old active male with significant osteoarthritis of the hip. He has not responded to conservative treatment. The patient wishes to undergo a hip resurfacing arthroplasty believing that there are some advantages over conventional hip replacement such as lower wear, lower dislocation rate, and the ability to participate in sports activities. The Health Plan has denied coverage for hip resurfacing arthroplasty on the basis there is insufficient evidence of its efficacy.According to the relevant literature, hip resurfacing arthroplasty has no proven benefit over conventional hip replacement. In fact, the results are inferior to those of conventional hip replacement. Higher failure rates are documented with resurfacing arthroplasty. In addition, resurfacing arthroplasty is not FDA-approved, whereas metal-on-metal and ceramic-on-ceramic hip replacements are FDA-approved and represent a better alternative to resurfacing procedures. Metal-on-metal and ceramic-on-ceramic hip replacements offer very low wear rates as well. Furthermore, many companies are now offering metal-on-metal with large femoral heads (as are used with resurfacing procedures) in their total hip replacement systems. At this time, there is insufficient evidence hip resurfacing arthroplasty results in a superior clinical outcome to total hip replacement. 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 56-year-old male with hip arthritis. He wishes to undergo a resurfacing procedure. The Health Plan indicates there is insufficient evidence demonstrating hip resurfacing arthroplasty is efficacious and has denied coverage for the procedure.The efficacy of hip resurfacing arthroplasty remains unproven. Previous attempts at resurfacing in the 1970's and 1980's were failures and were subsequently abandoned. Though interest in the procedure has recently been renewed, there are no long-term, prospective studies showing any benefit with the resurfacing procedure and metal-on-metal components. Studies are underway and results appear promising; however, no conclusions can be drawn at this time.Hip resurfacing arthroplasty is inferior to the standard of care (total hip replacement) and cannot be recommended until its benefits and risks have been established and confirmed. 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.