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

Physician 1: The patient is a 55-year-old male with hip arthritis. A request has been made for hip resurfacing arthroplasty. The Health Plan has denied this request on the basis that the requested procedure is considered experimental for treatment of the patients condition.Hip resurfacing arthroplasty remains an unproven procedure at this time. Previous attempts at resurfacing have been ineffective with high rates of failure and complication. While there has recently been renewed interest in hip resurfacing with the metal-on-metal prosthesis, the procedure has not been sufficiently studied in terms of risk, benefit and complications. Given the current lack of available data, 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. Therefore, the Health Plans denial should be upheld.Physician 2: The patient is a 55-year-old male with degenerative joint disease of the hip. He has had worsening pain over the past five years and wishes to undergo surgical intervention. The patient believes hip resurfacing arthroplasty is the most appropriate procedure for treatment of his condition. The Health Plan indicates there is insufficient data regarding the long-term safety and efficacy of the procedure.There is no Class I data establishing the superiority of hip resurfacing arthroplasty over conventional total hip replacement in patients such as this patient. To date, there is insufficient evidence that the requested procedure is more beneficial than standard interventions. Given the patients age, conventional total hip replacement is a more appropriate treatment option than a hip resurfacing procedure. 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 55-year-old man who has arthritis of his hip. He has selected hip resurfacing arthroplasty as the most appropriate option for treatment of his condition. The Health Plan indicates that the requested procedure has not been sufficiently evaluated and that there are standard therapies available for treatment of the patients condition.At issue is whether hip resurfacing arthroplasty is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Metal-on-metal 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 implant 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 similar fashion to a primary total hip arthroplasty.There are currently no randomized, controlled clinical trials of metal-on-metal hip resurfacing comparing this procedure to a traditional 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 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.Metal-on-metal hip resurfacing as an alternative to traditional total hip arthroplasty is currently promoted for use in younger, more active patients with osteoarthritis and/or avascular necrosis. The procedure is performed under an FDA study and is considered investigational. At this time, there is no evidence that metal-on-metal hip resurfacing is likely to be more beneficial than traditional total hip replacement for patients such as this patient. 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.