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

Physician 1: The patient is a 45-year-old male with bilateral hip arthritis. He is status post left hip metal-on-metal hip resurfacing. His provider has diagnosed the patient with severe osteoarthritis of the right hip and has recommended right hip metal-on-metal hip resurfacing. The Health Plan has denied authorization and coverage for metal-on-metal hip resurfacing on the basis it 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. At this time, metal-on-metal hip resurfacing 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 the requested procedure, it is not likely to be more beneficial than standard total hip replacement.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 2: The patient is a 45-year-old active male who underwent a metal-on-metal resurfacing arthroplasty of his left hip five years ago. Osteoarthritic involvement of the right hip progressed and became unresponsive to non-surgical measures. A similar metal-on-metal hip resurfacing has been recommended for the right hip. The Health Plan has denied coverage for the requested procedure on the basis it is considered investigational.Metal-on-metal hip resurfacing 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. A report by Amstutz, et al. describes clinical and radiographic 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 Amstutz, et al. report indicates the procedure is at an investigational stage and concludes that 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 is further expressed in the recently published 8th 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. His critique of the recent literature included the above mentioned report. The author concluded that metal-on-metal resurfacing is in the investigational stage. The current literature supports the conclusion that although metal-on-metal hip resurfacing is promising, it is still investigational. Thus, at this point there is theoretical support, but insufficient documented evidence to conclude metal-on-metal hip resurfacing is superior to traditional total hip replacement. Accordingly, 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 45-year-old man who underwent a left metal-on-metal hip resurfacing procedure five years ago. The patients contralateral hip is now arthritic and therefore, he wants to proceed with the same procedure on the right side. The Health Plan has denied the patients request indicating metal-on-metal hip resurfacing 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 joint arthroplasty and it is currently promote 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. To date, there is not sufficient evidence demonstrating metal-on-metal hip resurfacing is likely to be more beneficial than traditional total hip replacement. 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.