Total Hip Arthroplasty denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The enrollee has requested has requested authorization and coverage for hip replacement surgery. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee’s bilateral hip pain.Finding: In this patient’s case, evidence based medical guidelines and peer reviewed criteria have been met for the requested services. Evidence based medical guidelines recommend total hip arthroplasty when all reasonable conservative measures have been exhausted and other reasonable surgical options have been considered or implemented. Obesity is a relatively common finding in candidates for total joint arthroplasties.

Nature of Statutory Criteria/Case Summary: An enrollee has requested has requested authorization and coverage for total hip arthroplasty for treatment of his hip pain. Findings: The physician reviewer has found in this patient’s case, evidence based medical guidelines and peer reviewed criteria have been met for the requested services. Evidence based medical guidelines recommend total hip arthroplasty when all reasonable conservative measures have been exhausted and other reasonable surgical options have been seriously considered or implemented. Specific guideline criteria include exercise therapy (supervised physical therapy and/or home rehabilitation exercises) and medications (unless contraindicated, non-steroidal anti-inflammatory drugs or steroid injection).

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for the left hip arthroplasty procedure, or in the alternative, surgical procedure to shave the left femoral head and/or repair the left hip labral tear.Medical literature currently indicates that a total hip arthroplasty (THA) is indicated in end-stage hip osteoarthritis with a high degree of persistent pain when conservative treatment has failed the patient. This statement is valid for patients where the medical history, clinical examination, and radiographic findings are conclusive.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for total hip arthroplasty in the right hip for treatment of the enrollee’s chronic hip pain. Findings: The physician reviewer found that Evidence based medical guidelines recommend total hip arthroplasty when all reasonable conservative measures have been exhausted and other reasonable surgical options have been seriously considered or implemented. Criteria includes exercise therapy (supervised physical therapy and/or home rehab exercises) and medications. Subjective findings should include limited range of motion, or nighttime joint pain, or no pain relief with conservative care. Objective findings should include over 50 years of age and body mass index less than 35. Imaging findings of osteoarthritis on standing x-rays or arthroscopy are required.

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