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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 top hip arthroplasty is considered medically necessary for individuals with one or more of 
the following: 
 
1. Advanced Joint disease and all of the following (a,b,c): 
 
a. The joint disease is evidenced by conventional radiography, or magnetic resonance imaging (MRI) *; and 
b. Pain or functional disability attributable to the advanced joint disease; and 
c. Unsuccessful non-surgical medical management, when appropriate and attempted for a minimum of 3 
months. (When non-surgical medical management is not appropriate, the medical record must clearly document 
the basis for that conclusion); 
or 
 
2. Malignancy of the joint involving the bones or soft tissues of the pelvis or proximal femur; or 
3. Avascular necrosis (osteonecrosis of femoral head), or 
4. Fracture of the femoral neck 
5. Acetabular fracture 
6. Non-union or failure of previous hip fracture surgery, or 
7. Mal-union of acetabular or proximal femur fracture 
 
You can find this rule in Local Coverage Determination (LCD): Total Joint Arthroplasty (L36039) - Effective 
October 10, 2019. 
 
The rules say for total joint arthroplasty, there must be documentation of unsuccessful non-surgical medical 
management. Documentation should establish a history of a reasonable attempt at conservative therapy as 
appropriate for the patient in their current episode of care. Clinically appropriate non-surgical medical 
management typically includes one or more of the following: 
 
-anti-inflammatory medications and/or analgesics; and/or 
-flexibility and muscle strengthening exercises; and/or 
-supervised physical therapy; and/or 
-assistive device use; and/or 
-reasonable activity restrictions; and/or 
-weight reduction as appropriate; and/or 
-therapeutic injections into the joint as appropriate. 
 
You can find this rule in Local Coverage Article: Billing and Coding: Total Joint Arthroplasty (A57428) - 
Effective October 10, 2019. 
 
The rules say that non-surgical medical management may be inappropriate, ineffective or counterproductive 
when one or more of the following is present: 
 
-bone on bone articulation; and/or 
-severe deformity; and/or 
-Severe pain (particularly at rest) and significant disabling interference with activities of daily living (ADL). 
 
You can find this rule in Local Coverage Article: Billing and Coding: Total Joint Arthroplasty (A57428) - 
Effective October 10, 2019. 
 
The rules say that if the required criteria outlined in the Indications section above are not met, but the treating 
physician feels that performing the procedure is within the current standards of care, then the documentation 
must include, in addition to the above, other information which confirms that the services performed clearly 
were appropriate. This may include, for example, evidenced based clinical practice guidelines or published and 
peer reviewed literature in support. For example, if certain conservative measures are not necessary or 
appropriate for a given patient, it should be directly noted in the pre-procedure documentation. The clinical 
judgment of the treating physician is always a consideration if clearly addressed in the pre-procedure record 
and if consistent with the episode of care for the patient as documented in patient records and claim history. 
You can find this rule in Local Coverage Article: Billing and Coding: Total Joint Arthroplasty (A57428) - 
Effective October 10, 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.