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Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
The rules say that Noridian will consider total hip replacement surgery medically necessary in the following 
circumstances: 
 
Advanced joint disease demonstrated by: 
&#61623; Radiographic supported evidence or when conventional radiography is not adequate, magnetic 
resonance imaging (MRI) and/or computed tomography (CT) (in situations when MRI is non-diagnostic 
or not able to be performed) supported evidence (subchondral cysts, subchondral sclerosis, periarticular 
osteophytes, joint subluxation, severe joint space narrowing, avascular necrosis); AND 
&#61623; Pain that cannot be adequately controlled despite optimal conservative treatment or functional disability 
from injury due to trauma or arthritis of the joint; AND 
&#61623; If appropriate, history of unsuccessful conservative therapy (non-surgical medical management) that is 
clearly addressed in the pre-procedure medical record. (If conservative therapy is not appropriate, the 
medical record must clearly document the rationale for why such approach is not reasonable). Non-
surgical medical management is usually but not always implemented prior to scheduling total joint 
surgery. Non-surgical treatment as clinically appropriate for the patient?s current episode of care 
typically includes one or more of the following: 
&#61623;  
o anti-inflammatory medications or analgesics, or 
&#61623;  
o flexibility and muscle strengthening exercises, or 
&#61623;  
o supervised physical therapy [Activities of daily living (ADLs) diminished despite completing a 
plan of care], or 
&#61623;  
o assistive device use, or 
&#61623;  
o weight reduction as appropriate, or 
&#61623;  
o therapeutic injections into the hip as appropriate. 
In some circumstances, for example, if the patient has bone on bone articulation, severe deformity, pain or 
significant disabling interference with activities of daily living, the surgeon may determine that nonsurgical 
medical management would be ineffective or counterproductive and that the best treatment option, after 
 
 
explaining the risks, is surgical. If medical management is deemed appropriate, the medical record should 
indicate the rationale for and the circumstances under which this is the case. 
&#61623; Malignancy of the joint involving the bones or soft tissues of the pelvis or proximal femur; or 
&#61623; Avascular necrosis (osteonecrosis of femoral head); or 
&#61623; Fracture of the femoral neck; or 
&#61623; Acetabular fracture; or 
&#61623; Non-union or failure of previous hip fracture surgery; or 
&#61623; Mal-union of acetabular or proximal femur fracture 
Noridian will not consider a total hip replacement medically necessary when the following contraindications 
are present: 
Active infection of the hip joint or active systemic bacteremia 
 
Active urinary tract or dental infection 
  Active skin infection (exception recurrent cutaneous staph infections) or open wound within the planned 
surgical site of the hip. 
 
Rapidly progressive neurological disease except in the clinical situation of a concomitant displaced femoral 
neck fracture 
 
The following conditions are relative contraindications to total hip replacement and if such surgery is 
performed in the presence of these conditions, it is expected that the rationale for proceeding with the surgery 
under such circumstances is clearly documented in the medical record: 
 
Absence or relative insufficiency of abductor musculature 
 
Any process that is rapidly destroying bone 
 
Neurotrophic arthritis 
 
This local coverage determination (LCD) is only addressing medical necessity criteria for performing total hip 
replacement surgery. 
You can find this rule in the Local Coverage Determination (LCD): Total Hip Arthroplasty (L36573) effective 
December 1, 2019. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.