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

Physician 1: The patient is a 55-year-old male with end stage osteoarthritis of the right hip. He is self-employed and physically active. He installs security systems and has to crawl through narrow spaces during the course of his work. His activity, both at work and recreationally, is limited due to pain and stiffness and his condition has progressed rapidly.  The patient is requesting hip resurfacing arthroplasty which, was denied by the Health Plan based on a determination that the nature of the procedure is experimental/ investigational.In reviewing the surgical options available to the patient, his orthopedic surgeon indicated the patient was well educated on the subject.  Although the surgeon did indicate there was a slightly increased risk of failure due to cystic degeneration at the femoral head, he felt the patient was a candidate for hip resurfacing.  In view of the patients age and activity level, hip resurfacing does appear to offer added benefits.  The implant is more wear resistant and less likely to dislocate.  The procedure also preserves more femoral and acetabular bone stock so that revision to a conventional total hip replacement, if necessary, can be accomplished.  Based upon the information set forth above, I have determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 2: The patient is a 55-year old male with severe painful arthritis of the right hip.  He previously enjoyed a very active lifestyle.  The patient has researched alternatives to total hip replacement and has submitted a request for hip resurfacing arthroplasty to his Health Plan.  The Health Plan considers this an investigational procedure and has denied authorization.The efficacy of the procedure in question remains unproven.  There are no long-term prospective studies that show there is clear benefit over traditional hip replacement procedures and the extent of the related risks is still unknown.  Until studies have been published that demonstrate effectiveness, benefit, and long-term success of the hip surface replacement procedure, it cannot be recommended over conventional treatment.  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 3: The patient is a 55-year-old male with severe arthritis of the right hip who has had to curtail his recreational activities.  He has consulted with an orthopedic surgeon and has decided on right hip resurfacing arthroplasty as an alternative to total hip replacement. The Health Plan denied coverage for the proposed procedure because they consider it an experimental/investigational treatment of the patients condition.The procedure in question is still experimental and investigational. There are no long-term studies to support its use and long-term complications are as yet unknown. While metal-on-metal resurfacing is relatively new, previous attempts at hip resurfacing were unsuccessful and the procedure was abandoned by the orthopedic community. This procedure cannot be recommended over total hip arthroplasty until its outcomes are better established. 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.