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

Physician 1The patient is a 42-year-old man with a history of avascular necrosis dating to 1999. He is status post cord decompression of the right hip in March 2000. In addition, the patient reports that recently his pain has increased in intensity. His physician has recommended metal-on-metal total hip resurfacing. The Health Plan has denied authorization and coverage for the requested procedure on the basis that it is considered investigational for treatment of the patients medical condition. In patients under age 50 with severe degenerative joint disease, metal-on-metal total hip resurfacing is a better option than conventional total hip replacement because it spares more bone for revision hip surgery. This is an important concept in younger patients who require total hip replacement at less than 50 years of age. Metal-on-metal resurfacing is the best available option for relatively young total hip replacement candidates at the present time. Therefore, 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 2The patient is a 42-year-old man with avascular necrosis of the hip and severe hip pain. The patient wishes to undergo metal-on-metal total hip resurfacing. The Health Plan has denied this request indicating that the requested procedure is considered experimental for treatment of the patients medical condition. 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 is 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 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 3The patient is a 42-year-old man who has been diagnosed with right hip avascular necrosis (femoral head). He originally underwent cord decompression in 2000, but has had increasing hip pain and disability. Notes earlier in the year from his orthopedist indicate that the patients gait was minimally antalgic. He had a marked decrease in rotation at the hip. He has been considered for a total hip replacement, but feels that metal-on-metal total hip resurfacing will preserve his femur in the event that revision is necessary in the future. The Health Plan has denied authorization and coverage for the requested procedure on the basis that it is considered investigational for treatment of the patients medical condition.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 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.