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

Physician 1:  The patient is a 50-year-old female who had bilateral developmental hip dysplasia with shallow acetabula and degenerative changes more advanced on the left side, which is symptomatic. She researched her condition and decided that hip resurfacing arthroplasty is the procedure of choice for someone of her age and activity level. The Health Plan denied coverage for the proposed procedure on the basis that it is considered investigational. The major advantages of resurfacing include preservation of the femoral head and neck permitting standard total hip replacement (THR) if required at a later date. In addition, the procedure allows for a larger head size, which increases stability resulting in fewer dislocations and providing greater mobility. Although additional studies are being conducted, experience with total hip arthroplasty has been encouraging to date. Furthermore, the patient is an appropriate candidate for the procedure. For these reasons, 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 50-year-old female with degenerative joint disease of the left hip. She has consulted a specialist who has recommended a hip resurfacing arthroplasty, but the Health Plan denied authorization for the procedure based upon their determination that the procedure is experimental/investigational.There is currently insufficient scientific evidence supporting hip resurfacing arthroplasty as superior to more conventional hip replacement in terms of durability.  Resurfacing is associated with significant incidence of femoral loosening and is not particularly conservative in terms of acetabular bone removal. As such, the patient is likely to experience superior results from a standard treatment approach. 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 50-year-old female who is physically quite active and has end-stage arthritis. She consulted with an orthopedic surgeon who has recommended left hip surface replacement arthroplasty. The Health Plan has denied authorization for the procedure on the basis that there is insufficient evidence of its efficacy.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 implants is promoted as an alternative to total hip replacement for younger patients with osteoarthritis or avascular necrosis 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 fashion similar to primary total hip arthroplasty. Amstutz and Beaule, in the Journal of Bone and Joint Surgery, reported on a two to six year follow-up study of metal-on-metal surface replacement arthroplasties. 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 at 0.75%.In May 2006 the Food and Drug Administration approved the Birmingham Hip Resurfacing System. It is likely that within several months the remainder of the surface implants will be approved as well. Considering the patients age, activity level and the current data on the longevity of total hip arthroplasties in young patients, the requested procedure is likely to be superior to traditional total hip replacement and should be authorized.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.