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

Physician 1:  The patient is a 31-year-old male with congenital hip dysplasia. He presents with stiff gait, leg length discrepancy, hypotrophy of the left lower extremity and limited joint mobility.  Severe joint disease was confirmed by x-ray.  The patient has consulted a provider who recommends a musculoskeletal navigational system for hip replacement arthroplasty as an alternative to the standard total hip replacement. The Health Plan denied coverage for the proposed procedure because they consider it an investigational approach to treatment of degenerative joint disease.The musculoskeletal navigational system (computer-assisted) for total hip arthroplasty is a very new technology and purely experimental at this stage. The available data has not established that the outcomes are superior to conventional total hip arthroplasty or that the complication rates are lower.  This procedure offers no specific advantage for patients with congenital dysplasia of the hip. 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 31-year-old male with advanced left hip arthritis secondary to congenital hip dysplasia. His symptoms have reportedly become unresponsive to non-operative care and his quality of life has significantly deteriorated. The patients left hip x-rays demonstrated a complete loss of joint space with osteophyte formation as well as proximal femoral deformity secondary to congenital hip dysplasia. Additionally, a CT scan of the pelvis documented the 3-demensional pathology of the arthritic and dysplastic processes within the left hip. The patients provider requested authorization for left total hip arthroplasty and the use of a computer-assisted musculoskeletal navigational system. The Health Plan denied the request based on a determination that the procedure is experimental/investigational in this clinical setting.Although preliminary data suggests that the computer-assisted navigational system may help to achieve more accurate surgical outcomes for patients undergoing total hip arthroplasty, there is not sufficient evidence at this time to recommend its use. Therefore, in the patients case, there should be no authorization beyond the left total hip arthroplasty. The providers elective use of a computer-assisted navigational system should not be authorized as an additional procedure.  As such, 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 31-year-old male with severe arthritis of his left hip due to congenital hip dysplasia. There is also a significant leg length discrepancy with shortening of the left lower extremity. His orthopedic surgeon recommends a left hip replacement procedure with a computer-assisted navigational system and has submitted a request for authorization.  The Health Plan denied the request citing the investigational nature of the procedure in this clinical context.The computer-assisted navigational system attempts to give the surgeon a greater degree of accuracy in the positioning of the implant device utilized in joint replacement arthroplasty. Some of the larger medical centers are experimenting with this method.  In general however, the use of computer-assisted navigational systems for total hip replacement is in its infancy and is not representative of the current standard of care. There is no clearly established advantage for the patient with this approach.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 upheld.