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

Physician 1:  The patient is a 67-year-old male with a reportedly active lifestyle. He has had several years of bilateral hip pain which has limited his activities. In June 2006 his provider evaluated him for his complaints of right greater than left hip pain. The motion of the hips was limited in all planes with pain primarily in the groin and lateral hip areas. The patient had a Trendelenburg gait and an obvious external rotary deformity of the legs bilaterally. X-rays showed significant hypertrophic changes in both hips. The patient was concerned about activity limitations following traditional total hip replacement and his provider felt he was a good candidate for hip resurfacing. The patients request for authorization of hip resurfacing arthroplasty was denied by the Health Plan citing the investigational nature of the procedure.There are as yet, no large clinical trials that have determined the safety and efficacy of hip replacement over an extended period of time. Although the bone conserving nature procedure is believed to offer an advantage for active patients under the age of 55 who are likely to need additional surgery, this patient is 67 years-old and would not meet the criteria most often applied for consideration of hip resurfacing. The patients concerns about activity limitations with total hip replacement versus hip resurfacing were noted by his provider in June 2006. However, hip resurfacing still requires dislocation of the hip, placing the patient at risk for instability in certain positions and limiting some activities. Consequently, 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 2:  The patient is a 67-year-old male diagnosed with osteoarthritis of both hips. The record indicates his active lifestyle was affected due to pain with ambulation and stair climbing. The patients orthopedic surgeon reported in June 2006 the patient was concerned about having a total hip arthroplasty because of postoperative activity limitations and a desire to continue walking and bicycling activities. Physical examination by the surgeon identified a Trendelenburg gait, external rotational deformity of the hips bilaterally and decreased range of motion. X-rays revealed significant hypertrophic changes bilaterally and groin and lateral hip pain were also noted. The patients orthopedist recommended resurfacing arthroplasty for treatment of the patients hip pain. The Health Plan considers this procedure experimental and denied the patients request for authorization and coverage.Generally, hip resurfacing procedures are limited to those patients under the age of 60 years with an active lifestyle and who will most likely require additional hip surgery in the future. The hip resurfacing procedure conserves bone which would be important in anticipation of future surgery. The hip resurfacing procedure would not be recommended for this patient, as he clearly exceeds the age criteria. In addition, peer reviewed studies have not proven the long term safety of hip resurfacing or that it is better than the standard surgical treatment of hip arthroplasty. Until there are long-term clinical trials that prove the efficacy of hip resurfacing, the procedure remains investigational and cannot be considered superior to total hip arthroplasty. As such, 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 67-year-old male with complaints of bilateral hip pain, right greater than left, of several years duration. An examination by his orthopedic surgeon in June 2006 revealed limited hip motion in all planes, external rotary deformity of the bilateral legs and a Trendelenburg gait along with groin and lateral hip pain. X-rays of the hips reportedly showed significant hypertrophic changes on the right and the left. It appears the patient is knowledgeable as to treatment alternatives, and wishes to undergo right hip resurfacing arthroplasty. The Health Plan denied authorization and coverage for this procedure on the basis that it has not been shown to be safe and effective in the long term.Although the concept of resurfacing the hip joint is not new, it involves a technology separate and distinct from total hip replacement. Long-term peer-reviewed studies have yet to sufficiently addressed concerns such as stability, long-term performance and the effect on the remaining bone. In the event a conversion to total hip replacement is necessary, it is not know if the results of that second procedure would be altered in any way by the earlier hip resurfacing. It has not been established that hip resurfacing arthroplasty is superior to well-established total hip arthroplasty in the long term.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. The Health Plans denial should be upheld.