Hip Resurfacing Arthroplasty denials in California external review

What the reviewers wrote

Where the denial was overturned

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.

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.

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 67-year-old male with a reportedly active lifestyle. He has had several years of bilateral hip pain which has limited his activities. In June 2006 his provider evaluated him for his complaints of right greater than left hip pain. The motion of the hips was limited in all planes with pain primarily in the groin and lateral hip areas. The patient had a Trendelenburg gait and an obvious external rotary deformity of the legs bilaterally. X-rays showed significant hypertrophic changes in both hips. The patient was concerned about activity limitations following traditional total hip replacement and his provider felt he was a good candidate for hip resurfacing.

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 Resurfacing Arthroplasty, then check the rights and deadlines that apply to your plan.