Joint replacement surgery has been performed on millions of people over the
past several decades and has proved to be an important medical advancement in
the field of orthopedic surgery. The hip and knee are the two most commonly
replaced joints. The hip is a large weight bearing joint made up of two
components: a ball (femoral head) and socket (acetabulum). These components
are covered with articular cartilage and are bathed in synovial fluid produced
by a synovial membrane.  
  
Arthritis causes a severe limitation in the activities of daily living (ADLs),
including difficulty with walking, squatting, and climbing stairs. Pain is
typically most severe with activity and patients often have difficulty getting
mobilized when seated for a long time.  
  
Total hip replacement surgery is most often performed due to severe pain
caused by osteoarthritis (degenerative arthritis) of the hip joint. Rheumatoid
arthritis, traumatic arthritis, malignancy involving the hip joint and
osteonecrosis of the femoral head are also possible causes for hip replacement
surgery. The use of THR in patients with malignancy must be weighed against
considerations of life expectancy and possible alternative procedures to
relieve pain. The pain from the damaged joint usually limits activities of
daily living, such as walking, bathing and cooking. The pain can also cause
disruption of sleep due to the inability to lie on the hip while in bed. Pain
relief not achieved by taking non-steroidal anti-inflammatory medications and
failure to achieve symptom improvement with other conservative therapies such
as physical therapy, activity modification and (in some patients) assistive
device use are reasons for proceeding with a total hip replacement. The goal
of total hip replacement surgery is to relieve pain and improve or increase
patient function. Occasionally, there may be a need to perform a reoperation
on a previous total hip. This is often referred to as a revision total hip.
Circumstances that lead to the need for a revision total hip are continued
disabling pain, continued decline in function which can be attributed to
failure of the primary joint replacement. Failure can be due to infection
involving the joint, substantial bone loss in the structures supporting the
prosthesis, fracture, aseptic loosening of the components and wear of the
prosthetic components.  
  
**_Total Hip Arthroplasty (THA)_**  
  
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

*See the associated Billing and Coding article (linked below) for Documentation Requirements. 

**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  
  

This local coverage determination (LCD) is only addressing medical necessity
criteria for performing total hip replacement surgery.