Total Hip Arthroplasty (THA)

POLICY NUMBER

L.7.01.415

DESCRIPTION

Total hip arthroplasty (THA), also called total hip replacement (THR), is performed by removing the affected hip joint and replacing it with an artificial joint, called a hip implant or prosthesis. THA is most commonly performed as a treatment for deterioration of the hip joint due to a variety of musculoskeletal conditions, such as osteoarthritis, osteonecrosis, or other types of inflammatory arthritis. The aims of hip arthroplasty are relief of pain and improvement in joint function.

Traditionally, an inpatient hospital stay was required for all joint replacement procedures. Three primary factors made inpatient hospitalization necessary: pain control, physical therapy, and the possible need for blood transfusion. Advances in surgical technique, implants, comprehensive blood management, and multimodal pain management have strikingly reduced the hospital stay. Adjustments to anesthesia and other medications reduce pain more effectively while also minimizing side effects like nausea that could delay recovery.

Related medical policies -

• Hip Resurfacing

• Magnetic Resonance Imaging (MRI) of the Lower Extremity

• Magnetic Resonance Imaging (MRI) of the Abdomen and Pelvis

• Computed Tomography (CAT Scan) and Computed Tomographic Angiography (CTA) of Extremity or Joint

• Computer-Assisted Navigation for Orthopedic Procedure

• Postsurgical Home Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis

• Total Hip Arthroplasty (THA) - West Central and North East Region

POLICY

Total Hip Arthroplasty (THA) is considered medically necessary when ALL of the following criteria are met:

 1. A diagnosis of osteoarthritis (OA), osteonecrosis, or rheumatoid arthritis (RA), bone tumor involving the hip or acute femoral neck fracture,

 2. Radiographic evidence of hip joint damage,

 3. Significant persistent pain and functional limitations that interfere with activities of daily living, e.g., reduced walking distance, inability to work,

 4. Optimal medical management has been tried and failed, including but not limited to:

• Weight loss efforts

• Nonsteroidal anti-inflammatory drugs (NSAIDs)

• Disease modifying antirheumatic drugs (DMARDs)

• Cortisone injections

• Physical therapy

• Walking aids

• Physical activity reduction

Revision THA of the previous failed hip prosthesis with a new prosthesis may be considered medically necessary in individuals with significant increase in pain/swelling and/or decrease in knee function, in the presence of any of the following:

• Infection

• Wear and loosening

• Malalignment or malposition

• Fractures

• Instability

Ambulatory THA or revision THA is considered medically necessary in the ambulatory setting in adults (18 and older) that meet the above medical necessity criteria AND the following additional clinical requirements:

• American Society of Anesthesiologists (ASA) Physical Status classification of ASA PS 3 or less, AND

• Body Mass Index (BMI) 50 or less, AND

• Proactive treatment for possible Methicillin-Susceptible Staphylococcus Aureus (MSSA)/Methicillin-Resistant Staphylococcus Aureus (MRSA) preoperatively, AND

• Absence of ALL of the following contraindications: 1.  Pregnant2.  Known history of difficult airway/intubation3.  Fasting blood glucose level of 275 or greater on date of procedure4.  Known history or strong family history of malignant hyperthermia5.  Known history of psuedocholinesterase deficiency6.  Known history of recent myocardial infarction (less than 6 months) 7.  Pacemakers or Internal Automatic Defibrillators8.  Recent sepsis9.  History of cirrhosis or Chronic Obstructive Pulmonary Disease (COPD)10. On dialysis11. Expected operative time > 120 minutes12. Hemoglobin <12

The Company requires care coordination for ambulatory THA or revision THA Specialty Services, to determine 1) Whether medical necessity and medical policy guidelines have been met and 2) Whether these Specialty Services can be performed by a Blue Specialty Network Provider.

Benefits are only provided when these ambulatory THA or revision THA Specialty Services are performed by a Blue Specialty Network Provider in a setting coordinated and contracted with the Company.

POLICY EXCEPTIONS

State Health Plan (State and School Employees): The Total Hip Arthroplasty (THA) Medical Policy guidelines apply to State Health Plan Members effective 09/01/2017.

This Medical Policy is not applicable to Network Providers in the West Central and North East Regions of Mississippi. Refer to the  Total Hip Arthroplasty (THA) – West Central and North East Region Medical Policy for coverage and medical necessity guidelines. The West Central Region includes counties Attala, Bolivar, Carroll, Claiborne, Copiah, Grenada, Hinds, Holmes, Humphreys, Issaquena, Leake, Leflore, Madison, Montgomery, Rankin, Scott, Sharkey, Simpson, Smith, Sunflower, Tallahatchie, Warren, Washington, Yalobusha, and Yazoo. The North East Region includes counties Alcorn, Benton, Calhoun, Chickasaw, Choctaw, Clay, Itawamba, Lee, Lowndes, Monroe, Oktibbeha, Pontotoc, Prentiss, Tippah, Tishomingo, Union, and Webster.

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.

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.

POLICY HISTORY

02/04/2016: New policy added.

06/01/2016: Policy number L.7.01.415 added.

09/01/2017: Policy statement revised to change the medically necessary American Society of Anesthesiologists (ASA) Physical Status classification for outpatient THA or revision THA from "ASA PS 1 or ASA PS 2 only" to "ASA PS 3 or less." Also, Body Mass Index (BMI) changed from "35 or less" to "40 or less." Policy Exceptions section updated to note that the Medical Policy guidelines apply to State Health Plan Members effective 09/01/2017.

05/18/2018: Medical policy links updated in policy description.

01/01/2019: Revised language from "outpatient" to "ambulatory."

08/30/2019: Policy statement updated to change the Body Mass Index (BMI) requirement from "40 or less" to "50 or less." Added a link to the related Total Hip Arthroplasty (THA) - West Central Region Medical Policy. Policy Exceptions updated to state that this Medical Policy is not applicable to Network Providers in the West Central Region of Mississippi. Refer to the Total Hip Arthroplasty (THA) – West Central Region Medical Policy for coverage and medical necessity guidelines. The West Central Region includes counties Attala, Bolivar, Carroll, Claiborne, Copiah, Grenada, Hinds, Holmes, Humphreys, Issaquena, Leake, Leflore, Madison, Montgomery, Rankin, Scott, Sharkey, Simpson, Smith, Sunflower, Tallahatchie, Warren, Washington, Yalobusha, and Yazoo. Sources updated. 

10/01/2020: Policy Exceptions updated to add the North East Region of Mississippi, which includes counties Alcorn, Benton, Calhoun, Chickasaw, Choctaw, Clay, Itawamba, Lee, Lowndes, Monroe, Oktibbeha, Pontotoc, Prentiss, Tippah, Tishomingo, Union, and Webster.

11/08/2022: Policy reviewed. Policy statements unchanged. Policy Guidelines updated to change "Nervous/Mental Conditions" to "Mental Health Disorders" and "Medically Necessary" to "medical necessity."

12/07/2023: Policy reviewed; no changes.

07/01/2024: Policy updated to state that care coordination is required for Specialty Services.

03/11/2025: Policy reviewed; no changes.

SOURCE(S)

1. American Academy of Orthopaedic Surgeons (AAOS). Total Hip Replacement. http://orthoinfo.aaos.org/topic.cfm?topic=A00377

2. Journal of Clinical Anesthesia. The association of body mass index with same-day admission, postoperative complications, and 30-day readmission following day-case eligible joint arthroscopy.

3. Medical Policy Advisory Committee

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.

Medically Necessary Codes

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