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

Physician 1: The patient is a 27-year-old female who has osteoarthritis of the left hip and extreme joint laxity. She has undergone surgery to remove a benign tumor in her left hip. Her physician recommended she undergo metal-on-metal hip resurfacing, which was performed in January 2005. The Health Plan has denied reimbursement for the procedure on the basis it is considered investigational.Metal-on-metal hip resurfacing is an experimental procedure without proven efficacy. The current standard of care for the patients condition is a total hip replacement. This is the gold standard that all other treatments must be compared to. Metal-on-metal total hip resurfacing has not been effective and is out of favor given the extremely poor results of this technique. Given the current results of metal-on-metal resurfacing this procedure was not likely to be more beneficial than a total hip replacement by conventional means.Based upon the information set forth above, I have determined that the procedure at issue was 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 27-year-old who had a benign tumor of the hip. As a consequence of the tumor and its resection, she had cartilaginous destruction. She was previously physically active, participating in running and ballet. After the tumor was resected she had hip and back pain. In January 2005, the patient underwent metal-on-metal total hip resurfacing. She reports good results from the procedure. The patient has requested reimbursement for the metal-on-metal resurfacing procedure. The Health Plan has denied this request on the basis the procedure at issue is considered investigational.While the logic behind metal-on-metal total hip resurfacing is good, the efficacy of this procedure has not been demonstrated. More long-term follow up and comparison to other types of hip replacements will help determine if metal-on-metal resurfacing is of greater or similar efficacy than traditional hip replacements. To date, there is insufficient evidence that metal-on-metal resurfacing will avoid the need for early revision. Therefore, I have determined that the procedure at issue was 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 27-year-old woman who has left hip arthrosis secondary to removal of a benign tumor. She underwent metal-on-metal hip resurfacing in January 2005. She is requesting reimbursement for the procedure at issue. The Health Plan has denied this request on the basis metal-on-metal hip resurfacing is considered investigational.Metal-on-metal hip resurfacing as an alternative to total hip replacement and 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.Metal-on-metal hip resurfacing as an alternative to traditional total hip arthroplasty is currently promoted to be indicated in younger, more active patients with osteoarthritis and/or avascular necrosis. This is an extremely young patient to require total hip replacement; as such, there is sufficient evidence supporting the use of metal-on-metal hip resurfacing in this particular case. Therefore, I have determined that the procedure at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.