Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Norco and bilateral arthroplasty hip surgery.Findings:  The physician reviewer found that records document that this patient is being treated for bilateral hip osteoarthritis. The patient reported that she has been unable to quit smoking. The patients physical examination revealed that she presented in a wheelchair, stands up with great difficulty, and walks only a few steps with a severe limp. The provider noted that that it was difficult to measure the patients hip lengths because due to pain. The patient has expressed interest in bilateral hip arthroplasty surgeries and treatment with Norco. With regard to treatment with Norco, Holliday and colleagues noted that for patients with chronic non-cancer pain, the evidence base for the long-term use of opiates is mediocre, with weak support for minimal improvements in pain measures and limited evidence for functional restoration. Wilson and colleagues reported that preoperative opioid use preceding revision total knee arthroplasty has been associated with complications following surgery. This patients records include detailed documentation is evident regarding a urine drug screen that was noted as abnormal showing positive results for opiates and amphetamine. Moreover, the documentation does not include reports of adequate trials of non-opioid medications to control the pain. Therefore, the requested Norco is not medically necessary for treatment of this patient. With regard to the requested bilateral total hip replacement (THA), Gunther and colleagues concluded that THA should be performed when the expected treatment benefit outweighs the risks. In addition, the evidence suggests that a worse preoperative condition is associated with a poorer surgical outcome. Gademan and colleagues reported that the indication criteria for THA are based on limited evidence. The authors concluded that empirical research is needed, especially regarding domain specific cut-off values or ranges at which the best postoperative outcomes are achieved for patients. Furthermore, detailed documentation is not evident regarding trial and failure of recent, reasonable, and comprehensive less invasive conservative care measures. Additionally, the patient has failed to cease smoking, which the provider recommended prior to the requested procedure. There are limited large-scale studies demonstrating the long-term safety and efficacy of the requested bilateral hip arthroplasties in this clinical setting. For these reasons, the requested bilateral arthroplasty hip surgery is not medically necessary for treatment of this patient. All told, the requested Norco and bilateral arthroplasty hip surgery are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication and services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.