Hip Problem: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for right hip replacement. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the patient’s right hip osteoarthritis. The submitted documentation supports the medical necessity of the requested services. It is well documented that the patient has a history of chronic right hip pain, which has failed less invasive treatment in the past, including arthroscopic surgery for femoroacetabular impingement. A corticosteroid injection into the right hip resulted in a significant response with the pain level decreasing to eight out of a scale from one to ten, from ten out of a scale of one to ten. This confirmed that the patient’s pain source is the right hip joint and not the sacroiliac joint or the lower back.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an anterior hip revision using the same manufacturer of prosthetic as the enrollee’s current prosthetic. Findings: The physician reviewer found that the documentation provided supports the medical necessity for the requested services in this clinical setting. This patient’s clinical diagnosis includes component loosening complicated by a severe maximal rating of pain by the patient. The Orthopaedic Knowledge Update (OKU) noted studies, which compared anterior versus the posterior lateral approach. The studies demonstrated equivalence in terms of component positioning and hospital stay but the comparative studies demonstrated early higher complication rates in patients who have been treated with a direct anterior approach.

Where the denial was upheld

Physician 1: The patient is a 21-year-old male who has a congenital malformation of the right hip joint. In 1996, an Achilles tendon lengthening procedure was performed. According to his physician, the patient has had persistent hip pain on the right side for the past two years. In light of the patient’s young age, his physician has recommended hip resurfacing arthroplasty. The Health Plan has denied this request indicating the requested procedure is considered experimental.Review of the medical literature demonstrates short-term results from hip resurfacing arthroplasty are promising. The patient is very young for a hip replacement operation and revision is a certainty in his normal lifespan. Hip resurfacing is an appropriate option in this patient because it preserves bone stock for revision surgery.

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.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for hip problem was denied, the published record says the denial is worth fighting.