Total Hip Replacement denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for total hip replacement of the right hip. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee’s right hip pain.In this patient’s case, evidence based peer-reviewed literature have been met for the requested services. The patient has chronic right hip pain that did not respond to conservative treatment or arthroscopy with debridement and chondroplasty. At the time of surgery, the provider found evidence of grade III and grade IV chondromalacia. According to the records, postoperative improvement was temporary and the patient continues to be in pain that interferes with activities with activities of daily living.

A 60-year-old female enrollee has requested total hip replacement at a facility with a comprehensive hemophilia program and a coordinated team of experts experienced in performing complex orthopedic surgical procedure on individuals with von Willebrand’s disease for treatment of her von Willebrand’s disease. Findings: The physician reviewer found that this patient’s laboratory values are consistent with type I von Willebrand’s disease (Haberichter, et al). The records indicate that she is in need of hip arthroplasty which is a surgical intervention that can produce significant blood loss. For this surgery to be safely performed, the patient needs effective hemostasis, which requires rigorous and emergent monitoring of her von Willebrand’s disease factor levels and aggressive transfusion of factor concentrates (Federici, et al).

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for left hip replacement surgery. Hip and knee osteoarthritis are highly prevalent and disabling conditions. Education, exercise, and weight loss are the cornerstones of management, complemented by nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroid injections, and adjunctive medications. However, total joint replacement is an effective treatment option for patients with advanced symptoms and structural damage.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for right total hip replacement surgery. Hip osteoarthritis is a highly prevalent and disabling condition. Education, exercise, and weight loss are the cornerstones of management, complemented by nonsteroidal anti-inflammatory drugs, corticosteroid injections, and adjunctive medications. For patients with advanced symptoms and structural damage, total joint replacement effectively relieves pain. Total hip arthroplasty has shown great success in relieving joint pain and disability in the treatment of end-stage degenerative joint diseases and trauma. In this case, the patient is being treated for right hip atrophies and calcification of the hip. The patient presents with right hip pain, located at the hip, groin, and buttock.

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