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

Physician 1: The patient is a 21-year-old male who has a congenital malformation of the right hip joint. In 1996, an Achilles tendon lengthening procedure was performed. According to his physician, the patient has had persistent hip pain on the right side for the past two years. In light of the patients young age, his physician has recommended hip resurfacing arthroplasty. The Health Plan has denied this request indicating the requested procedure is considered experimental.Review of the medical literature demonstrates short-term results from hip resurfacing arthroplasty are promising. The patient is very young for a hip replacement operation and revision is a certainty in his normal lifespan. Hip resurfacing is an appropriate option in this patient because it preserves bone stock for revision surgery. With this in mind, hip resurfacing arthroplasty is the best procedure for the patient. 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 21-year-old male with hip arthritis secondary to developmental hip dysplasia. His hip symptoms have become progressive and non-responsive to standard conservative care. A resurfacing hip arthroplasty has been recommended for alleviation of pain and improvement in function. The Health Plan has determined that resurfacing arthroplasty of the hip is considered experimental.Metal-on-metal resurfacing hip arthroplasty 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, including the report by Amstutz, et al. in the Journal of Bone and Joint Surgery in January 2004. In that article, the author describes clinical and radiologic 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 authors concluded continued close follow-up is needed to better define the results and indications for this procedure. The cautious appraisal of metal-on-metal resurfacing hip arthroplasty is further expressed in the recently published 9th 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 and concludes from his detailed review that surface replacement using metal-on-metal bearings are currently in the investigational stage.Thus, the current literature supports the conclusion that hip resurfacing arthroplasty, although promising, remains an unproven procedure. 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 21-year-old man who has a congenital malformation of his right hip joint. In 1996, the patient had a tendo-Achilles lengthening procedure. His hip pain is persistent and appears to be quite disabling. The patient has consulted a provider who indicates the patient is likely to benefit from hip resurfacing. Of note is the fact that the radiographs show significant hip dysplasia, head deformity, and missing superolateral one-third of the head. Some joint space narrowing is determined as well. Joint congruity cannot be restored with specific rotation of the hip.The Health Plan has denied coverage for hip resurfacing arthroplasty on the basis it is considered investigational.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 joint 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. 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.