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

Physician 1:  The patient is an active 48-year-old male with bilateral hip osteoarthritis.  In 2002 he had a metal-on-metal resurfacing arthroplasty of the right hip and reports the treatment has been unbelievably successful. He is now requesting authorization for the same procedure for his left hip, which has become painful due to progression of the arthritis.  The Health Plan denied this request because the procedure is considered experimental/ investigational.The file contains the recommendations of the physicians who evaluated the patient in regard to his hip pain and literature which addresses patient select, implant design and fixation and the surgical technique for the hip resurfacing procedure. It appears the patient is an appropriate candidate for hip resurfacing arthroplasty based on the available data.  In light of the patients previous success with the hip resurfacing procedure and his age and activity level, I have determined that the requested procedure is likely to be more beneficial for treatment of his medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 2:  The patient is a 48-year-old male who has previously undergone hip resurfacing arthroplasty for treatment of his severe osteoarthritis.  The patient works as an athletic coach at the college level and wishes to maintain his active lifestyle.  The patient is pleased with the results of the 2002 right hip resurfacing arthroplasty and has submitted a request for resurfacing of the left hip.  The Health Plan considers this an investigational procedure and has denied authorization.The overall efficacy of the hip resurfacing procedure remains unproven.  There are no long-term prospective studies demonstrating a benefit over traditional hip replacement procedures and the extent of the related risks is still not clear.  Previous attempts at resurfacing the hip led to abandonment of the procedure in the United States.  Until studies have been published that demonstrate effectiveness, benefit, and long-term success of the surface replacement procedure, it cannot be recommended over conventional treatment.  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. The Health Plans denial should be upheldPhysician 3:  The patient is a 48-year-old male who is physically very active.  He instructs in Tae Kwon Do at a university center.  He had right hip resurfacing performed four years ago.  The patients contralateral hip is now symptomatic and he would like to proceed with left hip replacement arthroplasty. The Health Plan denied authorization citing the experimental/investigational nature of the procedure.Hip resurfacing as an alternative to total hip replacement has been performed since the early 70s with published reports in 1978.  In the initial experience with metal against thin poly shells, the failure rate in short to mid-term cases was high and enthusiasm for the procedure lessened in the 80s.  Work has continued with metal-on-metal resurfacing procedures and the design has improved significantly over 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 having been treated with resurfacing can be approached in a manner similar to a primary total hip arthroplasty.There are as yet no randomized controlled clinical trials of metal-on-metal hip resurfacing arthroplasty comparing this procedure to a traditional total hip replacement.  In 2004 Amstutz and Beaule reported on a two to four year follow up study of the metal-on-metal resurfacing procedure. Four hundred hips were treated in a group of young and potentially physically active participants. Three percent of the hips were converted to total hip replacements with other complications including component mismatch, heterotopic bone growth, and trochanteric bursitis. The dislocation rate was only 0.75 percent. This patient has had previous success with the hip resurfacing on the right, and one would expect the left hip resurfacing procedure to be equally successful.  I believe that for this patient, the requested procedure is likely to be more beneficial for treatment of his medical condition than any available standard therapy. The Health Plans denial should be overturned.