Total Hip Resurfacing*

Medical Policy: 07.01.36 
Original Effective Date: May 2007 
Reviewed: April 2012 
Revised: August 2011 

Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary based on contract, and individual member benefits must be verified. Wellmark determines medical necessity only if the benefit exists and no contract exclusions are applicable. This medical policy may not apply to FEP. Benefits are determined by the Federal Employee Program.

This Medical Policy document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy will be reviewed regularly and be updated as scientific and medical literature becomes available.

Description: 

Total hip resurfacing, investigated in a broader range of patients including those with osteoarthritis, rheumatoid arthritis, and advanced avascular necrosis, may be considered an alternative to total hip arthroplasty, particularly in young active patients who would potentially outlive a total hip prosthesis. The primary advantage of total hip resurfacing compared to total hip replacement is that it conserves bone. Therefore, if a patient should require further surgery in the future, subsequent revisions would be facilitated by that conserved bone mass.

The Buechel-Pappas Integrated Total Hip Replacement has been approved by the U.S. Food and Drug Administration (FDA) for total hip resurfacing. The weight-bearing surfaces of this device are composed of a ceramic femoral component and a polyethylene acetabular component. There has also been interest in metal-on-metal designs as a technique to reduce the debris wear particles. The Conserve® Plus (Wright Medical Technology) is a metal-on-metal design that has received premarket approval by the FDA in November 2009.  The Cormet 2000 hemiarthroplasty device has 510(k) marketing clearance from the FDA.

In May 2006, the FDA granted PMA (Premarket Approval) to the Birmingham Hip Resurfacing (BHR) system for use in patients requiring primary hip resurfacing arthroplasty for non-inflammatory or inflammatory arthritis.

The FDA lists the following contraindications to the use of total hip resurfacing:

• Patients with infection or sepsis
• Patients who are skeletally immature
• Patients with any vascular insufficiency, muscular atrophy, or neuromuscular disease severe enough to compromise implant stability or postoperative recovery
• Patients with bone stock inadequate to support the device, including severe osteopenia or a family history of severe osteoporosis or osteopenia
• Patients with osteonecrosis or avascular necrosis with >50% involvement of the femoral head
• Patients with multiple cysts of the femoral head
• Females of childbearing age
• Patients with known moderate-to-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

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Prior Approval: 

Prior appoval is recommended. Submit a prior approval now.

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Policy: 

Total hip resurfacing arthroplasty with an FDA approved device may be considered medically necessary for patients with degenerative hip joint disease, or severe arthritis, or rheumatoid arthritis, or advanced avascular necrosis of the hip and meet ALL of the following criteria:

• Skeletally mature, and
• Patient  with BMI of 39 or less, and
• Have failed conservative management, and would otherwise require total hip replacement surgery, and 
• Patient does not have any contraindications listed above

Patient with BMI equal or greater than 40 requires medical director review.   

Total hip resurfacing in patients not meeting the above criteria is considered investigational.

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Procedure Codes and Billing Guidelines: 

• To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
• There is no specific code for this procedure.
• CPT 27299 unlisted procedure, pelvic or hip joint.
• HCPCS S2118 Metal-on-metal total hip resurfacing, including acetabular and femoral components

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Selected References: 

• Treacy RB, McBryde CW, Pynsent PB. Birmingham hip resurfacing arthroplasty. A minimum follow-up of five years. J Bone Joint Surg Br 2005; 87(2):167-70.
• Shimmin AJ, Back D. Femoral neck fractures following Birmingham hip resurfacing: a national review of 50 cases. J Bone Joint Surg Br 2005; 87(4):463-4.
• Glyn-Jones S, Gill HS, McLardy-Smith P et al. Roentgen stereophotogrammetric analysis of the Birmingham hip resurfacing arthroplasty. A two-year study. J Bone Joint Surg Br 2004; 86(2):172-6.
• Itayem R, Arndt A, Nistor L et al. Stability of the Birmingham hip resurfacing arthroplasty at two years. A radiostereophotogrammetric analysis study. J Bone Joint Surg Br 2005; 87(2):158-62.
• TARGET [database online]. Plymouth Meeting (PA): ECRI; 2006 November;  Metal-on-metal (MOM) total hip resurfacing for arthritis. Available: http://www.ecri.org.
• Alberta Heritage Foundation for Medical Research. MOM hip resurfacing for young, active adults with degenerative hip disease. Edmonton, Alberta: Alberta Heritage Foundation for Medical Research; 2002 Mar 1. (Technote; no. 33).
• Allison C. Minimally invasive hip resurfacing. Ottawa (ON): Canadian Coordinating Office for Health Technology Assessment (CCOHTA); 2005. 4 p. (Issues in Emerging Health Technologies; no. 65).
• Guidance on the use of metal on metal hip resurfacing arthroplasty. London (UK): National Institute for Clinical Excellence (NICE); 2002.
• Ontario Health Technology Advisory Committee. Metal-on-metal total hip resurfacing arthroplasty: health technology policy assessment. Toronto: Ministry of Health and Long-Term Care, Medical Advisory Secretariat; 2006 Feb 21. 56 p.
• FDA Summary of Safety and Effectiveness Data 1. GENERAL INFORMATION Device Generic Name: Prosthesis, Hip, Semi-constrained, Resurfacing, metal/metal, hybrid ... Available at www.fda.gov/cdrh/pdf4/p040033b.pdf Accessed on line 4/13/2007.
• Target [database online].ECRI August 2007. Metal-on-metal total hip resurfacing for degenerative hip disease. Available: http://www.ecri.org.
• Blue Cross Blue Shield Association. Metal-on-metal total hip resurfacing. Chicago (IL): Blue Cross Blue Shield Association; 2007 Jun. 43p. (TEC Assessment Program; Vol.22, no.3).
• ECRI Institute. Metal Ion Release Following Metal-on-Metal Hip Resurfacing or Replacement. Plymouth Meeting (PA): ECRI Institute; 2011 Mar 04. 10 p. [ECRI hotline response]. Also available: http://www.ecri.org.
• ECRI Institute. Metal-on-metal total hip resurfacing for degenerative hip disease. Plymouth Meeting (PA): ECRI Institute; 2011 November. [ECRI emerging technology evidence report]. Also available: http://www.ec ri.org.
• American Academy of Orthopaedic Surgeons (AAOS). Modern Metal-on-metal Hip Implants: A Technology Overview. V1.0. December 2, 2011. Available at: http//www.aaos.org/research/overviews/Metal_On_Metal.pdf. Accessed 3/31/12.

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Policy History: 

Date                                        Reason                               Action

May 2011                               Annual review                    Policy renewed

August 2011                                                                    Policy revised

April 2012                              Annual review                    Policy renewed

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Wellmark medical policies address the complex issue of technology assessment of new and emerging treatments, devices, drugs, etc.   They are developed to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Wellmark medical policies contain only a partial, general description of plan or program benefits and do not constitute a contract. Wellmark does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Wellmark or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. Our medical policies may be updated and therefore are subject to change without notice.

*Current Procedural Terminology © 2012 American Medical Association. All Rights Reserved.