Osteoarthritis Of The Hip denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1: The patient is an active 51-year-old male with osteoarthritis who wishes to proceed with hip resurfacing arthroplasty. His right hip has been the source of increasing pain over the past four years and his ability to participate in regular activities has been affected. The Health Plan considers hip resurfacing an experimental/investigational procedure, and has denied authorization.There is currently mid-term follow-up data to support the use of hip resurfacing in relatively young patients who would otherwise require total hip replacement. This patient is only 51 years old and appears to be very active. He will most likely need a revision of the hip joint in his lifetime. Hip resurfacing will preserve his bone stock for a future revision procedure.

Physician 1The patient is a 58-year-old physically active female with severe osteoarthritis of the right hip dating back to 2002. The patient’s symptoms and disability have become progressively worse. She has had diagnostic hip injection and a scan, which have confirmed the diagnosis. The patient has consulted a provider who has recommended hip resurfacing as opposed to total hip replacement. The Health Plan indicates hip resurfacing is considered investigational.Review of current medical literature suggests that hip resurfacing is likely to provide a favorable long-term outcome compared to standard treatment. Given the patient’s relatively young age and continued high level of activity, hip resurfacing is more appropriate than traditional total hip replacement. Hip resurfacing is a medically reasonable procedure and is medically indicated for the patient’s condition.

Where the denial was upheld

Physician 1: The patient is a 51-year-old man with hip pain secondary to arthritis. He underwent metal-on-metal hip resurfacing in August 2004. The patient has requested reimbursement for the procedure at issue. The Health Plan has denied the patient’s request indicating the procedure at issue is considered experimental.Metal-on-metal hip resurfacing is an experimental procedure without proven efficacy. The current standard of care for the patient’s condition is a total hip replacement. This is the gold standard that all other treatments must be compared to. Metal-on-metal total hip resurfacing has not been effective and is out of favor given the extremely poor results of this technique.

Physician 1: The patient is a 50-year-old male who has had approximately a one-year history of right hip pain. On exam he was found to have osteoarthritis with narrowing of the joint space and pistol grip deformity. Based on the patient’s history and current condition, the patient’s physician recommended the patient undergo a metal-on-metal resurfacing procedure. Authorization and coverage for the proposed procedure has been denied by the Health Plan on the basis it is considered investigational for treatment of the patient’s medical condition.The requested procedure is not the gold standard procedure for hip replacement as of this date. Previous surface replacements have been ineffective with high rates of failure and complications.

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 osteoarthritis of the hip, then check the rights and deadlines that apply to your plan.