Hip Resurfacing

POLICY NUMBER

A.7.01.80

DESCRIPTION

Hip resurfacing is an alternative to total hip arthroplasty (also known as hip replacement) for patients with advanced arthritis of the hip.Total hip resurfacingdescribes the placement of a shell that covers the femoral head together with implantation of an acetabular cup in patients with painful hip joints. Partial hip resurfacing is considered a treatment option for avascular necrosis with collapse of the femoral head. Available prostheses are metal-on-metal devices.

Total Hip Resurfacing

Total hip resurfacing has been investigated in patients with osteoarthritis, rheumatoid arthritis, and advanced avascular necrosis as an alternative to total hip arthroplasty, particularly in young active patients who would potentially outlive a total hip prosthesis. Therefore, hip resurfacing could be viewed as a time-buying procedure to delay the need for a total hip arthroplasty. Proposed advantages of total hip resurfacing compared with total hip arthroplasty include preservation of the femoral neck and femoral canal, thus facilitating revision or conversion to a total hip resurfacing, if required. In addition, the resurfaced head is more similar in size to the normal femoral head, thus increasing the stability and decreasing the risk of dislocation compared with total hip arthroplasty.

Total hip resurfacing has undergone various evolutions, with modifications in prosthetic design and composition and implantation techniques. For example, similar to total hip prostheses, the acetabular components of total hip resurfacing have been composed of polyethylene. However, over time it became apparent that device failure was frequently related to the inflammatory osteolytic reaction to polyethylene debris wear particles. Metal acetabular components have since been designed to improve implant longevity. Sensitivity to wear particles from metal-on-metal chromium and cobalt implant components are of increasing concern.

In 2006, the Birmingham Hip Resurfacing System (Smith & Nephew Orthopaedics), a metal-on-metal resurfacing system, was approved by the U.S. Food and Drug Administration (FDA) through the premarket approval process for use in patients requiring primary hip resurfacing arthroplasty for non-inflammatory or inflammatory arthritis. This decision was primarily based on a series of 2,203 patients (2,385 hips) who received this device by a single surgeon in England. A number of post approval conditions were required, including the following items:

• Study longer-term safety and effectiveness through 10-year follow-up of the first consecutive 350 cases in the 2,385 hip case cohort that was part of the premarket approval.

• Study the “learning curve” and the longer-term safety and effectiveness of the Birmingham Hip Resurfacing system in the United States by studying 350 patients at up to 8 sites where clinical and radiographic data will be assessed annually through 5 years and at 10 years. Also, determine cobalt and chromium serum concentration and renal function in these patients at 1, 4, and 10 years.

• Implement a training program to provide clinical updates to investigators.

Two additional metal-on-metal hip resurfacing systems have been approved: in 2007, the Cormet™ Hip Resurfacing System (Corin) and, in 2009, the Conserve® Plus Total Hip Resurfacing System (MicroPort Orthopedics). Both implants were approved for skeletally mature patients with either: non-inflammatory degenerative arthritis (eg, osteoarthritis and avascular necrosis); or inflammatory arthritis (eg, rheumatoid arthritis). (Note: patients with the latter arthritis might be individuals who, due to younger age or increased activity level, may not be suitable for traditional total hip arthroplasty because it would increase the possibility of requiring ipsilateral hip joint revision.)

Various devices have been cleared for marketing by the FDA through the 510(k) process for partial hip (femoral) resurfacing. Some surgeons may be using a femoral resurfacing component together with an acetabular cup (total arthroplasty component) as an "off-label" application.

Also, see the  Surgical Treatment of Femoroacetabular Impingement  medical policy.   

POLICY

Metal-on-metal total hip resurfacing with an FDA approved device system may be considered medically necessary as an alternative to total hip replacement when the individual:

• Is a candidate for total hip replacement; AND

• Is likely to outlive a traditional prosthesis; AND 

• Does not have a contraindication for total hip resurfacing (See Policy Guidelines).

Partial hip resurfacing with an FDA-approved device may be considered medically necessary in individuals with osteonecrosis of the femoral head who have one or more contraindications for metal-on-metal implants and meet the following criteria:

• The individual is a candidate for total hip replacement; AND 

• Is likely to outlive a traditional prosthesis; AND 

• The individual has known or suspected metal sensitivity or concern about potential effects of metal ions; AND 

• There is no more than 50% involvement of the femoral head; AND 

• There is minimal change in acetabular cartilage or articular cartilage space identified on radiography.

All other types and applications of hip resurfacing are considered investigational.

POLICY EXCEPTIONS

Federal Employee Program (FEP) may dictate that all FDA-approved devices, drugs or biologics may not be considered investigational and thus these devices may be assessed only on the basis of their medical necessity. 

POLICY GUIDELINES

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

The U.S. Food and Drug Administration (FDA) lists several contraindications for total hip resurfacing. These contraindications include, but are not limited to, the following:

• Bone stock is inadequate to support the device due to:

• • severe osteopenia or a family history of severe osteoporosis or severe osteopenia

  • osteonecrosis or avascular necrosis with more than 50% involvement of the femoral head

  • multiple cysts of the femoral head (more than 1 cm)

• Skeletal immaturity

• Vascular insufficiency, muscular atrophy, or neuromuscular disease severe enough to compromise implant stability or postoperative recovery

• Known moderate-to-severe renal insufficiency

• Severely overweight

• Known or suspected metal sensitivity

• Immunosuppressed or receiving high doses of corticosteroids

• Individuals with childbearing potential of childbearing age due to unknown effects on the fetus of metal ion release.

A 2012 FDA advisory panel of experts identified young males with larger femoral heads as the best candidates for hip resurfacing systems. The FDA has advised that a metal-on-metal hip implant should be selected only after determining that the benefit-risk profile of using a metal-on-metal hip implant outweighs that of using an alternative hip system. Factors to consider include the individual's age, sex, weight, diagnosis, and activity level. Individuals should be informed about the benefits and risks of metal-on-metal hip implants, including the risk that the hip implant may need to be replaced. Individual expectations and the potential complications of surgery with a metal-on-metal hip implant should be discussed.

Total hip resurfacing should be performed by surgeons who are adequately trained and experienced in the specific techniques and devices used.

Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Mental Health Disorders, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:

A.  consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and

B.  appropriate with regard to standards of good medical practice; and

C.  not solely for the convenience of the Member, his or her Provider; and

D.  the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.

For the definition of medical necessity, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.

Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.

POLICY HISTORY

11/2001: Approved Medical Policy Advisory Committee (MPAC).

2/7/2002: Investigational definition added.

5/8/2002: Type of Service and Place of Service deleted.

11/3/2004: Code Reference section completed.

2/18/2005: Policy reviewed, no changes.

3/13/2006: Policy reviewed, devices were updated, investigational policy statement unchanged.

9/18/2006: Coding updated. ICD9 2006 revisions added to policy.

4/30/2007: Policy updated to allow for metal-on-metal total hip resurfacing. CPT 27299, ICD-9 procedures 00.85 and 81.40 moved to covered. Added ICD-9 diagnosis 714.0, 715.0-715.9, 733.42.

5/16/2007: Policy reviewed, description updated. Added "who do not have contraindications for total hip resurfacing," and removed "who are likely to out live a traditional prosthesis," under the Policy section.

7/19/2007: Reviewed and approved by MPAC.

6/24/2008: Policy reviewed, no changes.

8/26/2008: Quarterly HCPCS code updates applied.

08/18/2010: Policy description updated regarding FDA approval of devices and treatment approaches. The total resurfacing policy statement was revised to add “is likely to outlive a traditional prosthesis” to the criteria. Added policy statements for partial resurfacing, which is considered medically necessary in specific conditions. Supporting explanations added to the policy guidelines. FEP verbiage added to the Policy Exceptions section. Added ICD-9 procedure codes 00.75, 00.86, and 00.87.

07/29/2011: Deleted "Total" from the policy title to align with the scope of the policy statement. Policy statement unchanged.

07/12/2012: Policy reviewed; no changes.

10/17/2013: Policy reviewed; no changes to policy statement. Policy guidelines updated regarding patient selection criteria.

11/25/2014: Policy reviewed; description updated regarding devices and metal-on-metal implants. Policy statements unchanged.

08/25/2015: Code Reference section updated for ICD-10.

11/06/2015: Policy description updated regarding metal-on-metal hip implants. Policy statements unchanged. Policy guidelines section updated to add medically necessary and investigative definitions.

05/31/2016: Policy number A.7.01.80 added.

09/13/2017: Policy description updated regarding hip resurfacing systems. Policy statements unchanged.

05/04/2018: Policy description updated regarding metal-on-metal implants. Investigational statement updated to change "total hip resurfacing" to "hip resurfacing."

05/13/2019: Policy reviewed; no changes.

05/26/2020: Policy reviewed; no changes.

07/22/2021: Policy description updated. Policy statements unchanged. Policy Guidelines updated to change "Nervous/Mental Conditions" to "Mental Health Disorders" and "Medically Necessary" to "medical necessity."

06/02/2022: Policy description updated. Policy statements unchanged.

05/22/2023: Policy description updated. Policy statements and Policy Guidelines updated to change "patient" to "individual."

05/22/2024: Policy reviewed; no changes.

05/15/2025: Policy reviewed; no changes.

SOURCE(S)

Blue Cross Blue Shield Association policy # 7.01.80

CODE REFERENCE

This may not be a comprehensive list of procedure codes applicable to this policy.

The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.

Covered Codes

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