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

Physician 1: The patient is a 49-year-old man with severe osteoarthritis of the hip. The patient has consulted an orthopedist who has recommended metal-on-metal hip resurfacing. The Health Plan has denied authorization for the requested procedure indicating that it is considered investigational. 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 2: The patient is a 49-year-old man with bilateral osteoarthritic changes in the hips. He was a prior skier. He has had progressive pain, now requiring narcotic control and complicated by some dyspepsia from chronic NSAID usage. Radiographs confirm severe arthritis on the left with obliteration of the joint space. The patient consulted a provider who recommended metal-on-metal hip resurfacing of the left hip or both hips in staged procedures. The patients provider indicates the patient will be better off with the metal-on-metal procedure in the event that a revision is needed in the future. He further indicates that on revision the patient may be able to have a less invasive procedure or possibly only a partial procedure (e.g., replacement of the ball and retention of the current socket, etc.). The Health Plan has denied coverage for metal-on-metal hip resurfacing on the basis it is considered experimental for treatment of the patients osteoarthritis. 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. Physician 3: The patient is a 49-year-old man with left-side osteoarthritis of the hip. He requires total hip replacement. He has requested coverage for metal-on-metal hip resurfacing. The Health Plan has denied his request on the basis that the requested procedure is considered investigational for treatment of the patients medical condition.In patients under age 50 with severe osteoarthritis, metal-on-metal hip resurfacing is a better option than a 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. It 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.