Appeal type: Experimental/Investigational
Decision: Upheld

Physician 1: The patient is a 58-year-old male who has severe osteoarthritis of the right hip. He has failed conservative management. His physician has recommended metal-on-metal hip resurfacing arthroplasty. The Health Plan has denied authorization and coverage for the requested procedure on the basis it is considered investigational.Metal-on-metal hip resurfacing arthroplasty is an experimental procedure without proven efficacy. The current standard of care for the patients condition is a total hip replacement. This is the gold standard to which all other treatments must be compared. Metal-on-metal hip resurfacing arthroplasty has not been effective and is out of favor given the extremely poor results of this technique. Furthermore, the long-term risks of the procedure are not known. Given the current results of hip resurfacing arthroplasty, the procedure is not likely to be more effective than a total hip replacement by conventional means.Based upon the information set forth above, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Physician 2: This patient is a 58-year-old male who is morbidly obese and has severe arthritis of the hip. He consulted with his orthopedic surgeon and one of the options discussed was metal-on-metal surface replacement of the hip to reduce the patients hip pain. The Health Plan has denied coverage for hip resurfacing indicating it is considered investigational for treatment of the patients condition. Hip resurfacing as an alternative to total hip replacement has been performed since the early 1970s. In the initial experience of metal against thin poly shells, the failure rate in short to mid-term cases became rather high and enthusiasm for the procedure lessened in the 1980s. However, there have been significant design improvements during the last decade. Currently, hip resurfacing with metal-on-metal implant is promoted as an alternative to total hip replacement for younger patients who would like to maintain a more active lifestyle. The procedure conserves acetabular bone stock, the femoral neck is not resected and the proximal femoral canal is not invaded. If at a later stage total hip replacement is necessary, a hip treated with resurfacing can be approached in a similar fashion as a primary total hip arthroplasty.There are currently no randomized, controlled clinical trials of metal-on-metal hip resurfacing comparing this procedure to a traditional total hip arthroplasty. Amstutz and Beaule in the Journal of Bone and Joint Surgery in January 2004 reported on a 2-6 year follow-up study of metal-on-metal surface replacement arthroplasties. The report includes 2.2 to 6.2 year follow-ups. The results indicate 400 hips were treated with this implant. The target group was younger and potentially physically active patients. Of the 400 hips, 3% were converted to total hip replacement at a later stage. Other complications included operations for component mismatch, removal of heterotopic bone, and re-operation for trochanteric bursitis. The dislocation rate was extremely low.Metal-on-metal hip resurfacing is an alternative to traditional total hip arthroplasty and is currently promoted to be indicated in younger, more active patients with osteoarthritis and/or avascular necrosis. The procedure is performed under a FDA study and is considered investigational. At this time, there is no evidence that metal-on-metal hip resurfacing is likely to be more beneficial than traditional total hip replacement for patients such as this patient. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3: The patient is a 58-year-old male with end stage osteoarthritis of the right hip for which a metal-on-metal hip resurfacing arthroplasty has been requested. The patients past medical history is remarkable for morbid obesity as defined by a height of 64, and a weight of 343 pounds with a body mass index of 41.5. His history is also remarkable for chronic lower extremity venous stasis and insufficiency as well as a clotting disorder, which requires chronic Coumadin anticoagulation. The patient and his provider contend that a metal-on-metal resurfacing arthroplasty may be superior to a traditional stemmed total hip arthroplasty given the patients young age and activity level. However, the patients provider has raised concerns that the resurfacing procedure may predispose the patient to greater risk of perioperative thromboembolic phenomenon because of the limb manipulation required during a resurfacing arthroplasty as opposed to a traditional hip replacement. The Health Plan has denied authorization for the requested procedure on the basis it remains investigational at this time. In summary, the current literature supports the conclusion that although metal-on-metal hip resurfacing is promising, it is still investigational. At this point, there is no long-term data confirming the safety of high-level activity after metal-on-metal hip resurfacing. Thus, there is insufficient documented evidence to conclude that metal-on-metal hip resurfacing is superior to standard treatment modalities. Furthermore, in the case of this patient there is no clinical data indicating any emergent need for operative intervention. Accordingly, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.