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

Physician 1: The patient is a 51-year-old man with hip pain secondary to arthritis. He underwent metal-on-metal hip resurfacing in August 2004. The patient has requested reimbursement for the procedure at issue. The Health Plan has denied the patients request indicating the procedure at issue is considered experimental.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 51-year-old male with osteoarthritis of the right hip who underwent metal-on-metal hip resurfacing on 8/10/04. The patient contended that a resurfacing arthroplasty of the hip would be of greater benefit to him than a traditional total hip replacement with a stemmed femoral component. The Health Plan has denied coverage for the metal-on-metal hip resurfacing deeming it an investigational procedure. 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 hip 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 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 51-year-old male who has arthritis of the right hip. In August 2004, the patient underwent metal-on-metal hip resurfacing of the right hip. A request has been made for reimbursement for the procedure at issue. The Health Plan has denied this request indicating the efficacy of metal-on-metal hip resurfacing has not been established in peer-reviewed literature.Traditional total hip arthroplasty has been performed in Europe and the United States since the mid to late 1960s. There has been significant improvement over the years to this most valuable procedure for treatment of osteoarthritis of the hip. Bearing surfaces have been improved, biologic fixation has been improved, and stem designs and fixation have been improved. With modern techniques and choices of bearing surfaces such as metal-on-metal, ceramic-on-ceramic, ceramic-on-metal, etc. The longevity of total hip replacement is 80-90% at 20 years.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 hip arthroplasty and it is currently promoted 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. In the case of this patient, at age 51 he could have benefited equally from a traditional total hip arthroplasty. 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.