Hip Osteoarthritis denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1The patient is a 42-year-old male with severe hip degenerative joint disease who requires total hip replacement. The patient has requested authorization for surface replacement arthroplasty. The Health Plan has denied authorization for the requested procedure indicating that it is considered investigational.At age 42 a surface replacement arthroplasty is a better option than a conventional total hip replacement because it spares more bone for revision hip surgery. This is an important concept in younger patients who require total hip replacement at less than 50 years of age. There is literature supporting the use of metal-on-metal surface replacement. It is certainly the best available option for relatively young total hip replacement candidates at the present time.

Physician 1: The patient is an active 48-year-old male with bilateral hip osteoarthritis. In 2002 he had a metal-on-metal resurfacing arthroplasty of the right hip and reports the treatment has been “unbelievably successful.” He is now requesting authorization for the same procedure for his left hip, which has become painful due to progression of the arthritis. The Health Plan denied this request because the procedure is considered experimental/ investigational.The file contains the recommendations of the physicians who evaluated the patient in regard to his hip pain and literature which addresses patient select, implant design and fixation and the surgical technique for the hip resurfacing procedure. It appears the patient is an appropriate candidate for hip resurfacing arthroplasty based on the available data.

Where the denial was upheld

Physician 1: The patient is a 62-year-old female who is highly active. She has advanced right hip arthrosis. Her surgeon has recommended total hip replacement surgery. Her treating physician discussed with the patient different bearing surfaces. The patient decided to pursue metal-on-metal hip resurfacing. The Health Plan denied the patient's request for the proposed procedure on the basis it is considered investigational.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.

Physician 1: The patient is a highly active 54-year-old female with severe left hip osteoarthritis. Several examining physicians have recommended surgical intervention for this patient. The patient believes metal-on-metal hip resurfacing is the most appropriate treatment for her condition. The Health Plan indicates there is insufficient evidence establishing the long-term safety and efficacy of the requested procedure. Metal-on-metal hip resurfacing preserves bone stock and will make revision easier in the future. The patient is likely to wear-out a conventional total hip replacement due to her highly active lifestyle. Metal-on-metal resurfacing is the best available option for relatively young total hip replacement candidates at the present time.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving hip osteoarthritis, then check the rights and deadlines that apply to your plan.