Coverage Indications, Limitations, and/or Medical Necessity
Joint replacement surgery has been performed on millions of people over the past several decades and has proved to be an important medical advancement in the field of orthopedic surgery. The hip and knee are the two most commonly replaced joints. The hip is a large weight bearing joint made up of two components: a ball (femoral head) and socket (acetabulum). These components are covered with articular cartilage and are bathed in synovial fluid produced by a synovial membrane.
Arthritis causes a severe limitation in the activities of daily living (ADLs), including difficulty with walking, squatting, and climbing stairs. Pain is typically most severe with activity and patients often have difficulty getting mobilized when seated for a long time.
Total hip replacement surgery is most often performed due to severe pain caused by osteoarthritis (degenerative arthritis) of the hip joint. Rheumatoid arthritis, traumatic arthritis, malignancy involving the hip joint and osteonecrosis of the femoral head are also possible causes for hip replacement surgery. The use of THR in patients with malignancy must be weighed against considerations of life expectancy and possible alternative procedures to relieve pain. The pain from the damaged joint usually limits activities of daily living, such as walking, bathing and cooking. The pain can also cause disruption of sleep due to the inability to lie on the hip while in bed. Pain relief not achieved by taking non-steroidal anti-inflammatory medications and failure to achieve symptom improvement with other conservative therapies such as physical therapy, activity modification and (in some patients) assistive device use are reasons for proceeding with a total hip replacement. The goal of total hip replacement surgery is to relieve pain and improve or increase patient function. Occasionally, there may be a need to perform a reoperation on a previous total hip. This is often referred to as a revision total hip. Circumstances that lead to the need for a revision total hip are continued disabling pain, continued decline in function which can be attributed to failure of the primary joint replacement. Failure can be due to infection involving the joint, substantial bone loss in the structures supporting the prosthesis, fracture, aseptic loosening of the components and wear of the prosthetic components.
Total Hip Arthroplasty (THA)
Noridian will consider total hip replacement surgery medically necessary in the following circumstances:
Advanced joint disease demonstrated by:
- Radiographic supported evidence or when conventional radiography is not adequate, magnetic resonance imaging (MRI) and/or computed tomography (CT) (in situations when MRI is non-diagnostic or not able to be performed) supported evidence (subchondral cysts, subchondral sclerosis, periarticular osteophytes, joint subluxation, severe joint space narrowing, avascular necrosis); AND
- Pain that cannot be adequately controlled despite optimal conservative treatment or functional disability from injury due to trauma or arthritis of the joint; AND
- If appropriate, history of unsuccessful conservative therapy (non-surgical medical management) that is clearly addressed in the pre-procedure medical record. (If conservative therapy is not appropriate, the medical record must clearly document the rationale for why such approach is not reasonable). Non-surgical medical management is usually but not always implemented prior to scheduling total joint surgery. Non-surgical treatment as clinically appropriate for the patient’s current episode of care typically includes one or more of the following:
- anti-inflammatory medications or analgesics, or
- flexibility and muscle strengthening exercises, or
- supervised physical therapy [Activities of daily living (ADLs) diminished despite completing a plan of care], or
- weight reduction as appropriate, or
- therapeutic injections into the hip as appropriate.
In some circumstances, for example, if the patient has bone on bone articulation, severe deformity, pain or significant disabling interference with activities of daily living, the surgeon may determine that nonsurgical medical management would be ineffective or counterproductive and that the best treatment option, after explaining the risks, is surgical. If medical management is deemed appropriate, the medical record should indicate the rationale for and the circumstances under which this is the case.
- Malignancy of the joint involving the bones or soft tissues of the pelvis or proximal femur; or
- Avascular necrosis (osteonecrosis of femoral head); or
- Fracture of the femoral neck; or
- Non-union or failure of previous hip fracture surgery; or
- Mal-union of acetabular or proximal femur fracture
*See the associated Billing and Coding article (linked below) for Documentation Requirements.
Indications for Replacement/Revision of Total Hip Arthroplasty
• Loosening of one or both components; or
• Fracture or mechanical failure of the implant; or
• Recurrent or irreducible dislocation; or
• Infection; or
• Treatment of a displaced periprosthetic fracture; or
• Clinically significant leg length inequality not amenable to conservative management; or
• Progressive or substantial bone loss; or
• Bearing surface wear leading to symptomatic synovitis or local bone or soft tissue reaction; or
• Clinically significant audible noise; or
• Adverse local tissue reaction
Noridian will not consider a total hip replacement medically necessary when the following contraindications are present:
• Active infection of the hip joint or active systemic bacteremia
• Active urinary tract or dental infection
• Active skin infection (exception recurrent cutaneous staph infections) or open wound within the planned surgical site of the hip.
• Rapidly progressive neurological disease except in the clinical situation of a concomitant displaced femoral neck fracture
The following conditions are relative contraindications to total hip replacement and if such surgery is performed in the presence of these conditions, it is expected that the rationale for proceeding with the surgery under such circumstances is clearly documented in the medical record:
• Absence or relative insufficiency of abductor musculature
• Any process that is rapidly destroying bone
• Neurotrophic arthritis
This local coverage determination (LCD) is only addressing medical necessity criteria for performing total hip replacement surgery.
Summary of Evidence
Analysis of Evidence
(Rationale for Determination)