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

Physician 1: The patient is a highly active 54-year-old female with severe left hip osteoarthritis. Several examining physicians have recommended surgical intervention for this patient. The patient believes metal-on-metal hip resurfacing is the most appropriate treatment for her condition. The Health Plan indicates there is insufficient evidence establishing the long-term safety and efficacy of the requested procedure. Metal-on-metal hip resurfacing preserves bone stock and will make revision easier in the future. The patient is likely to wear-out a conventional total hip replacement due to her highly active lifestyle. 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 2: The patient is a 54-year-old woman with hip arthritis. She has requested authorization and coverage for metal-on-metal hip resurfacing. The Health Plan has denied this request on the basis the long-term efficacy of the proposed procedure has not been established. 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 3: The patient is a 54-year-old woman who is requesting authorization for metal-on-metal hip resurfacing. The patient indicates she teaches movement classes for a living and cannot function at this time. She reports she is increasingly unable to work. She has a limp. She feels that she should not have to have a total hip replacement when she can conserve good bone. The patient also feels that a total hip replacement would not allow her to function in her usual work capacity.The patient consulted a surgeon who noted the patient has decreased range of motion and generalized ligamental laxity. He also noted obliteration of the joint space of the right hip. He reported there were no definitive cysts on the right. The surgeon felt hip resurfacing was a good option because of stability and range of motion. The patients orthopedist noted that the patient is young and would benefit from metal-on-metal hip resurfacing because of her lifestyle and decreased complication rate. The Health Plan has denied coverage for metal-on-metal hip resurfacing on the basis that the procedure is considered investigational.While the logic behind metal-on-metal 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 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.