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

Physician 1The patient is a 42-year-old male with severe hip degenerative joint disease who requires total hip replacement. The patient has requested authorization for surface replacement arthroplasty. The Health Plan has denied authorization for the requested procedure indicating that it is considered investigational.At age 42 a surface replacement arthroplasty is a better option than a conventional total hip replacement because it spares more bone for revision hip surgery. This is an important concept in younger patients who require total hip replacement at less than 50 years of age. There is literature supporting the use of metal-on-metal surface replacement. It is certainly the best available option for relatively young total hip replacement candidates at the present time. Therefore, I have determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 2The patient is a 42-year-old man with left hip osteoarthritis. He is requesting a metal-on-metal surface arthroplasty. The Health Plan has denied the request on the basis that the requested procedure is considered investigational.The requested procedure is not the gold standard procedure for hip replacement as of this date. Previous surface replacements have been ineffective with high rates of failure and complications. The procedure requested, while somewhat different from the failed procedures of the past, has not been evaluated in terms of risk, benefit and complications, as well as long-term success of the prosthesis in question. Given the current results of surface replacement arthroplasty it is not likely to be more beneficial than standard treatments available at this time.Based upon the information set forth above, 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 3The patient is a 42-year-old man who is a construction glazier with an expected high level of activity. The description of his pain and limitations is consistent with the examination showing a limited range of motion, which elicited pain. The radiographs show advanced osteoarthritis with loss of the joint space in the left hip with a pistol grip deformity of his proximal femur. The patient has the same deformity of his right femur potentially putting it at risk for future degeneration from the same cam impingement that has led to his left hip disease. He has failed conservative options, including NSAIDs due to proteinuria, and recently has been on a reasonably large dose of daily narcotics. The patient wishes to undergo hip surface replacement arthroplasty. The Health Plan has denied the patients request indicating the requested procedure is considered investigational.The patients history, exam, and radiographs indicate a hip arthroplasty is medically justified in order to preserve function and relieve pain. The patients age group (under 50) is notorious for having less positive results than older, more sedentary patients. This has been linked to the higher number of gait cycles in younger patients as seen in previous studies.Standard total hip arthroplasty in the younger patient has an early revision rate approaching 20%. All of the solutions, highly cross-linked polyethylene, metal/metal, or ceramic/ceramic, have been FDA approved through various devices based on intermediate European and limited American IDE series. The speed of that response is indicative of the consensus regarding standard polyethylene. None of the alternative surfaces have long-term, large population outcomes, especially in America. It is reasonable to offer the younger, informed patient the options with their specific risks. It is not uncommon for younger, more active patients to prefer the option of metal/metal out of concern over ceramic fracture and possible eventual polyethylene wear.It is reasonable to assume with a high degree of certainty that the requested procedure would at minimum give the patient at least as good a chance of prosthetic longevity in the intermediate period as a standard total hip with or without alternative bearing surfaces. This is based on the limited experience to date. Alternatives to the proposed surgery do not have any more certainty in this age group based on currently available literature. Given his young age, the greater ease of revision should it be necessary, and higher demands with less risk of dislocation, the patient is likely to have a better overall outcome both short- and long-term with the requested procedure. Based upon the information set forth above, I have determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.