Appeal type: unknown
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 Medicare will consider Total Hip Arthroplasty (THA) medically reasonable and necessary 
when three or more of the following indications are met: 
1. Advanced joint disease demonstrated by radiographic supported evidence or when conventional 
radiography is not adequate, magnetic resonance imaging (MRI) supported evidence (subchondral 
cysts, subchondral sclerosis, periarticular osteophytes, joint subluxation, joint space narrowing, 
avascular necrosis); 
2. Pain and functional disability from injury due to trauma or arthritis of the joint; activities of daily living 
(ADLs) are diminished despite completing a plan of care with activity restrictions as is reasonable, 
assistive device use, appropriate weight reduction, flexibility and muscle strengthening exercises with 
supervised physical therapy. 
3. History of unsuccessful conservative treatment or non-surgical medical management that is clearly 
documented in the pre-procedure medical record. Non-surgical medical management is usually 
implemented for 3 months or more to assess effectiveness. Conservative treatment, as clinically 
appropriate for the patients current episode of care, typically includes one or more of the following: 
anti-inflammatory medications, analgesics, or therapeutic injections when appropriate, with physical 
therapy or assist devices. 
4. Distinct structural abnormalities  
o Malignancy of the joint involving the bones or soft tissues of the pelvis or proximal femur; 
o Avascular necrosis (osteonecrosis of femoral head); 
o Fracture of the femoral neck; Acetabular fracture; 
o Non-union or failure of previous hip fracture surgery; Mal-union of acetabular or proximal 
femur fracture; 
5. Failed previous Hip Arthroplasty necessitating revision as indicated by the following:  
o Loosening, fracture or mechanical failure of the implant; 
o Instability of one or more components; 
o Recurrent or irreducible dislocation; 
o Infection; 
o Displaced periprosthetic fracture; 
o Clinically significant leg length inequality; 
o Progressive soft tissue or bone reaction or substantial bone loss, 
o Clinically significant audible noise; or o Bearing surface wear leading to symptomatic synovitis 
o Other disease or destructive process that renders the hip impaired to the extent to preclude 
employment or functional activities 
Limitations 
The following are considered not reasonable and necessary and therefore will be denied: 
1. TKA and THA will not be considered reasonable and necessary when the above indications are not met. 
2. Medicare will consider a total knee replacement or total hip replacement not medically reasonable and 
necessary when the following contraindications are present:  
 Active infection of the hip or knee joint or active systemic bacteremia 
 Active skin infection or open wound within the planned surgical site of the hip or knee 
 Progressive neurological disease, etiologic for pain, instability or disability 
You can find this in the Local Coverage Determination (LCD): Lower Extremity Major Joint Replacement 
(Hip and Knee). 
 
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.