Medical Policy

Effective Date:06/01/2012 Title:Hip Resurfacing Arthroplasty
Revision Date:08/01/2017 Document:BI351:00
CPT Code(s):S2118
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

 

1)    Hip resurfacing arthroplasty requires preauthorization.

2)    Hip resurfacing arthroplasty is an alternative to total hip replacement in younger, active patients with chronic pain and disability from hip arthritis.

3)    Hip resurfacing, partial or total, is not covered for developmental dysplasia.

4)    Partial hip resurfacing arthroplasty is covered for individuals with osteonecrosis of the femoral head who require surgical intervention.

Medical Statement

Total Hip Resurfacing:

Hip resurfacing arthroplasty (HRA) with U.S. Food and Drug Administration (FDA) approved device being used for its approved labeled indications is considered medically necessary and is covered as an alternative to total hip replacement for the treatment of hip disease in patients who are younger than age 65 and who meet the following criteria:

  • Have chronic, persistent pain and/or disability from inflammatory or non–inflammatory arthritis, AND
  • Have failed typical nonsurgical management, such as pharmacotherapy and physical therapy, AND
  • Are otherwise fit and active, AND
  • Have minimally abnormal proximal femoral bone geometry and bone quality, AND
  • Would otherwise receive a conventional primary total hip replacement, but are likely to live longer than a conventional total hip replacement (THR) is expected to last.

 

Partial Hip Resurfacing:

Partial hip resurfacing arthroplasty is considered medically necessary for the treatment of osteonecrosis of the femoral head when there is failure or intolerance to nonsurgical management.

 

Contraindications for HRA include:

  • Patients with active or suspected infection in or around the hip joint
  • Patients who are skeletally immature
  • Patients with poor bone stock inadequate to support the device including:
    • Patients with severe osteopenia
    • Patients with a family history of severe osteoporosis or severe osteopenia
    • Patients with osteonecrosis or avascular necrosis (AVN) with > 50% involvement of the femoral head (regardless of Ficat Grade)
    • Patients with multiple cysts of the femoral head (> 1 cm)
  • Patients with any vascular insufficiency, muscular atrophy, or neuromuscular disease severe enough to compromise implant stability or postoperative recovery
  • Females of child bearing age due to unknown effects on the fetus of metal ion release
  • Patients with known moderate or severe renal insufficiency
  • Patients who are immunosuppressed with diseases such as AIDS or persons receiving high doses of corticosteroids
  • Patients who are severely overweight
  • Patients with known or suspected metal sensitivity (e.g., jewelry)
  • Developmental dysplasia

Codes Used In This BI:

S2118           Total hip resurfacing

Limits
Intentially left empty
Reference

1)    Back DL, Dalziel R, et al. (2005) Early results of primary Birmingham hip resurfacings. An independent prospective study of the first 230 hips. J Bone Joint Surg Br, 2005; 87:324-9.

2)    Beaule PE, Amstutz HC, et al. (2004) Surface arthroplasty for osteonecrosis of the hip: hemiresurfacing versus metal-on-metal hybrid resurfacing. J Arthroplasty, 2004; 19(8 suppl 3):54-8.

3)    Daniel J, Pynsent PB, McMinn DJ. (2004) Metal-on-metal resurfacing of the hip in patients under the age of 55 years with osteoarthritis. J Bone Joint Surg Br, 2004; 86:177-84.

4)    Girard J, Lavigne M, et al. (2006) Biomechanical reconstruction of the hip: a randomised study comparing total hip resurfacing and total hip arthroplasty. J Bone Joint Surg Br, 2006; 88:721-6.

5)    Grecula MJ. (2005) Resurfacing arthroplasty in osteonecrosis of the hip. Orthop Clin North Am 2005; 36(2):231-42.

6)    McGrath MS, Marker DR, Seyler TM et al. (2009) Surface replacement is comparable to primary total hip arthroplasty. Clin Orthop Relat Res 2009; 467(1):94-100.

7)    National Institute for Clinical Excellence, Technical Appraisal No. 44.  June 2002, reviewed Feb 2005.  Guidance on the use of metal on metal hip resurfacing arthroplasty.

8)    Pollard TC, Baker RP, et al. (2006) Treatment of the young active patient with osteoarthritis of the hip. A five- to seven-year comparison of hybrid total hip arthroplasty and metal-on-metal resurfacing. J Bone Joint Surg Br, 2006; 88:592-600

9)    Schmalzried TP, Silva M, et al. (2005) Optimizing patient selection and outcomes with total hip resurfacing. Clin Orthop Relat Res, 2005; 441:200-4.

10)  Hayes Medical Technology Report July 13, 2006, updated June 28, 2010, archived Aug 13, 2011

11) US FDA Ctr for Devices and Radiological Health. (2006) Summary of safety and effectiveness data: Birmingham Hip Resurfacing (BHR) System. http://www.fda.gov/cdrh.

12) US FDA. Hip Implant Systems.  http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/MetalonMetalHipImplants/ucm241594.htm

13)  Costa ML, Achten J, Parsons NR, et al. Total hip arthroplasty versus resurfacing arthroplasty in the treatment of patients with arthritis of the hip joint: single centre, parallel group, assessor blinded, randomized controlled trial. The BMJ. 2012; 344:e2147.

14)  McMinn DJW, Daniel J, Ziace H and Pradhan C. Indications and results of hip resurfacing. International Orthopedics (SICOT). 2011; 35:231-237

15)  Sershon R, Balkissoon R and Valle CJ. Current indications for hip resurfacing arthroplasty in 2016. Curr Rev Musculoskeletal Med. 2016; 9(1):84-92

Addendum:

Effective 08/01/2017:  Added more current references that support continued use of this procedure with carefully selected patients.

Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.

Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.