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

Physician 1: The patient is a 62-year-old female who is highly active. She has advanced right hip arthrosis. Her surgeon has recommended total hip replacement surgery. Her treating physician discussed with the patient different bearing surfaces. The patient decided to pursue metal-on-metal hip resurfacing. The Health Plan denied the patient's request for the proposed procedure on the basis it is considered investigational.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 as 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 is an alternative to traditional total hip arthroplasty and it is currently promoted to be indicated in younger, more active patients with osteoarthritis and/or avascular necrosis. The procedure is performed under a 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.Physician 2: The patient is a 62-year-old active female with radiographically documented osteoarthritis of her right hip. The pain secondary to her hip osteoarthritis has become unresponsive to standard conservative measures. She has been deemed an appropriate candidate for hip arthroplasty. The patient has specifically requested a metal-on-metal resurfacing hip replacement athroplasty. The Health Plan has denied the patients request stating that metal-on-metal hip resurfacing arthroplasty is an experimental/investigational procedure.Metal-on-metal hip resurfacing arthroplasty represents a promising alternative to traditional total hip arthroplasty for the treatment of hip osteoarthritis in young patients. Short-term results have now been published, including the report by Amstutz, et al. in the Journal of Bone and Joint Surgery in January 2004. In that article, the author describes clinical and radiologic results of the first 400 hips treated with a metal-on-metal resurfacing prosthesis. The follow-up study spanned two to six years and comprised hips with an average follow-up of three and a half years. During the study period, 3% of the metal-on-metal arthroplasties were easily revised to an arthroplasty with a traditional stemmed component. This preliminary experience was viewed by the authors as encouraging; however, the authors concluded continued close follow-up is needed to better define the results and indications for this procedure. The cautious appraisal of metal-on-metal hip resurfacing arthroplasty is further expressed in the recently published 9th Edition of Orthopaedic Knowledge Update from the American Academy of Orthopaedic Surgeons. The author summarizes the current status of bearing surfaces in total joint arthroplasty and concludes from his detailed review that surface replacement using metal-on-metal bearings are currently in the investigational stage.Thus, the current literature including the preliminary report of the surgeon in this case, supports the conclusion that metal-on-metal resurfacing hip arthroplasty, although promising, is an investigational 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 62-year-old highly active female with a long-standing history of hip pain. She has been diagnosed with osteoarthritis. The patients physician recommended metal-on-metal hip surfacing, which the Health Plan has denied due to a lack of scientific evidence in peer-reviewed medical literature to support its efficacy.Metal-on-metal hip resurfacing is still in experimental/investigational studies. Short-term data is sparse, with no long-term prospective study establishing its effectiveness. In addition, the procedures risks are uncertain. Furthermore, there are other treatments available for this patient. At this time, metal-on-metal hip resurfacing cannot be recommended as there is very little data to warrant its general use. 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.