Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to pre-approve THA surgery. We decided that the Plan does not have to pre-approve inpatient admission.
You asked the Plan to pre-approve THA surgery and inpatient admission. You say that you are appealing with records. The Plan says that the denial of authorization for this service is correct.
We decided that the Plan has to pre-approve THA surgery.
The Plan follows Medicare rules. The rules say that THA surgery is covered when the clinical criteria listed in the previous section have been met, and the enrollee does not have certain contraindications to the surgery. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve THA surgery. Our reviewer says that the enrollee meets the Medicare criteria for total hip arthroplasty (THA) surgery. Our physician reviewer found the enrollee reports pain which interferes with activities of daily living. He has tried physical therapy for over 12 weeks, non-steroidal anti-inflammatory drugs (NSAIDs), and external support devices without substantial benefit. Radiographs demonstrate advanced degenerative changes of the left hip, with subchondral sclerosis, periarticular osteophyte formation, joint subluxation, and joint space narrowing. The enrollee has below average risk for all components of the National Surgical Quality Improvement Program (NSQIP) except for risk of surgical site infection, readmission, return to the operating room, and sepsis, for which the risk if average. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of THA surgery have been met. Therefore, we decided that the Plan has to pre-approve THA surgery.
We also decided that the Plan does not have to pre-approve this surgery to be provided on an inpatient hospital basis.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve inpatient admission. Our reviewer says that the enrollee does not need to have this surgery done on an inpatient hospital basis. Our physician reviewer found the documentation does not support the need for inpatient hospital status for this surgery. The surgery may be performed safely at an outpatient or observation status. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient admission have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient admission.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.