Hip Replacement denials in California external review
In the California DMHC record, independent physician reviewers decided 107 published external-review cases involving Hip Replacementand overturned the plan’s denial in 32.7%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Conditions behind Hip Replacement denials
| Category | Decisions | Overturned |
|---|---|---|
| Osteoarthritis | 40 | 32.5% |
| Hip Problem | 29 | 37.9% |
| Hip Problem Pain | 21 | 19% |
| Joint Problem | 4 | 0% |
What the insurer actually argued
| Reason given | Decisions | Overturned |
|---|---|---|
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 70 | 38.6% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 35 | 22.9% |
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 a 50-year-old female who had bilateral developmental hip dysplasia with shallow acetabula and degenerative changes more advanced on the left side, which is symptomatic. She researched her condition and decided that hip resurfacing arthroplasty is the procedure of choice for someone of her age and activity level. The Health Plan denied coverage for the proposed procedure on the basis that it is considered investigational. The major advantages of resurfacing include preservation of the femoral head and neck permitting standard total hip replacement (THR) if required at a later date. In addition, the procedure allows for a larger head size, which increases stability resulting in fewer dislocations and providing greater mobility. Although additional studies are being conducted, experience with total hip arthroplasty has been encouraging to date.
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.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California external-review outcomes. Other state and federal programs have different eligibility rules, processes, and current availability; the rates here do not transfer to those programs or predict an individual result. Excerpts are quoted verbatim from the public record and describe this treatment generally, not any individual case.
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 Replacement, then check the rights and deadlines that apply to your plan.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · AGGREGATES + DEIDENTIFIED DECISION EXCERPTS/REFERENCE IDS · METHODOLOGY