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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 state that Noridian will consider total hip replacement surgery medically necessary in the following circumstances: Advanced joint disease demonstrated by: 

-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 

-Pain that cannot be adequately controlled despite optimal conservative treatment or functional disability from injury due to trauma or arthritis of the joint; AND 

-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: 

- anti-inflammatory medications or analgesics, or 

- flexibility and muscle strengthening exercises, or 

- supervised physical therapy [Activities of daily living (ADLs) diminished despite completing a plan of care], or 

- assistive device use, or 

- weight reduction as appropriate, or 

- 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. 

- Malignancy of the joint involving the bones or soft tissues of the pelvis or proximal femur; or 

- Avascular necrosis (osteonecrosis of femoral head); or 

- Fracture of the femoral neck; or 

- Acetabular fracture; or 

- Non-union or failure of previous hip fracture surgery; or 

- Mal-union of acetabular or proximal femur fracture Indications for Replacement/Revision of Total Hip Arthroplasty 

- Loosening of one or both components; or 

- Fracture or mechanical failure of the implant; or 

- Recurrent or irreducible dislocation; or 

- Infection; or 

- Treatment of a displaced periprosthetic fracture; or 

- Clinically significant leg length inequality not amenable to conservative management; or 

- Progressive or substantial bone loss; or 

- Bearing surface wear leading to symptomatic synovitis or local bone or soft tissue reaction; or 

- Clinically significant audible noise; or 

- Adverse local tissue reaction 

Limitations 

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 

You can find this in the Local Coverage Determination (LCD): Total Hip Arthroplasty (L36573).

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.