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Horizon BCBSNJ
Uniform Medical Policy ManualSection:Surgery
Policy Number:068
Effective Date: 11/01/2018
Original Policy Date:11/14/2006
Last Review Date:05/12/2020
Date Published to Web: 09/19/2018
Subject:
Hip Resurfacing

Description:
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IMPORTANT NOTE:

The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.

Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.

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Hip resurfacing is an alternative to total hip arthroplasty (THA; also known as hip replacement) for patients with advanced arthritis of the hip. Total hip resurfacing (THR) describes 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.

PopulationsInterventionsComparatorsOutcomes
Individuals:
  • With indication for hip replacement who would outlive a traditional prosthesis and no contraindication for hip resurfacing
Interventions of interest are:
  • Metal-on-metal total hip resurfacing device
Comparators of interest are:
  • Any traditional total hip arthroplasty device
Relevant outcomes include:
  • Symptoms
  • Change in disease status
  • Functional outcomes
  • Health status measures
  • Quality of life
  • Treatment-related morbidity
Individuals:
  • With indication for hip replacement who would outlive a traditional prosthesis and no contraindication for hip resurfacing
Interventions of interest are:
  • Partial hip resurfacing device
Comparators of interest are:
  • Any traditional total hip arthroplasty device
Relevant outcomes include:
  • Symptoms
  • Change in disease status
  • Functional outcomes
  • Health status measures
  • Quality of life
  • Treatment-related morbidity

BACKGROUND

Hip resurfacing is an alternative to total hip arthroplasty (THA; also known as total hip replacement) for patients with advanced arthritis of the hip. Total hip resurfacing (THR) describes the placement of a shell that covers the femoral head together with implantation of an acetabular cup. Partial hip resurfacing is considered a treatment option for avascular necrosis with collapse of the femoral head.

THR has been investigated in patients with osteoarthritis, rheumatoid arthritis, and advanced avascular necrosis as an alternative to THA, 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 THA. Proposed advantages of THR compared with THA include preservation of the femoral neck and femoral canal, thus facilitating revision or conversion to a THR, 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 THA.

THR 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 THR 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.

Regulatory Status

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 through the premarket approval process for use in patients requiring primary hip resurfacing arthroplasty for noninflammatory or inflammatory arthritis. This decision was primarily based on a series of 2385 patients who received this device by a single surgeon in England. A number of postapproval conditions were required, including the following items:

    • Study longer term safety and effectiveness through 10-year follow-up of the initial 350 patients in the patient 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 one, four, and ten 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: noninflammatory 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 THA because it would increase the possibility of requiring ipsilateral hip joint revision.)

Various devices have been cleared for marketing by the Food and Drug Administration 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.

Food and Drug Administration product code: NXT.

Related Policies

  • None

Policy:
(NOTE: Effective December 3, 2018, Horizon Blue Cross Blue Shield of New Jersey (“Horizon BCBSNJ”) contracted with TurningPoint Healthcare Solutions, LLC (TurningPoint) to manage our Surgical and Implantable Device Management Program (“the Program”). TurningPoint conducts Prior Authorization and Medical Necessity Determination reviews of certain orthopedic services to be provided to members included in the scope of the Program. The scope of the program includes members enrolled in the Horizon BCBSNJ plans for the effective dates noted below.

For services rendered December 3, 2018 and after, the Program includes members enrolled in Horizon BCBSNJ Fully Insured plans.

For services rendered July 15, 2019 and after, the Program includes members enrolled in Horizon BCBSNJ Medicare Advantage plans.

For services to be rendered January 20, 2020 and after, the Program will also include members enrolled in New Jersey State Health Benefits Program (SHBP)/School Employees’ Health Benefits Program (SEHBP) plans.

Please note that this policy’s criteria and guidelines only apply to members enrolled in plans that DO NOT participate in the Program. Visit our TurningPoint webpage for instructions on accessing the policy criteria and guidelines that TurningPoint will follow as they conduct PA/MND reviews as part of the Program. You may also call TurningPoint at 1-833-436-4083, Monday through Friday between 8 a.m. and 5 p.m., Eastern Time to request policy content.

NOTE: For Medicare Advantage, Medicaid and FIDE-SNP, please refer to the Coverage Sections below for coverage guidance.)


1. Metal-on-metal total hip resurfacing with a device system approved by the U.S. Food and Drug Administration (FDA) is considered medically necessary as an alternative to total hip replacement when all of the following criteria are met:
    a. Member is a candidate for total hip replacement; AND
    b. Radiographic evidence of osteoarthritis, rheumatoid arthritis, posttraumatic arthritis, or osteonecrosis; AND
    c. Member has failed or is not a candidate for osteotomy; AND
    d. Pain and/or functional disability interferes with member's ability to perform activities of daily living (ADLs); AND
    e. Limited hip joint range of motion, pain with passive range of motion, and antalgic gait on physical examination; AND
    f. Normal proximal femoral bone quality and geometry; AND
    g. Failure of at least 3 months of conservative treatment including medications, muscle strengthening/flexibility exercises, activity modifications, weight reduction (as appropriate), assistive device when appropriate, injections when appropriate; AND
    h. Member is likely to outlive a traditional prosthesis; AND
    i. Member does not have any of the following contraindications for total hip resurfacing:
      • Bone stock inadequate to support the device due to:
        o severe osteopenia or a family history of severe osteoporosis or severe osteopenia
        o osteonecrosis or avascular necrosis with more than 50% involvement of the femoral head
        o multiple cysts of the femoral head (>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 (BMI >40)
      • Known or suspected metal sensitivity
      • Immunosuppressed or receiving high doses of corticosteroids
      • Females of child bearing age due to unknown effects on the fetus of metal ion release
      • Active systemic infection or skin infection of the joint/planned surgical site
      • Age >65 years
      • Anatomic abnormality of the femoral head that cannot be sufficiently restored.
2. Partial hip resurfacing with an FDA-approved device is considered medically necessary in members with osteonecrosis of the femoral head who have one or more contraindications for metal-on-metal implants and meet the following criteria:
    • The member is a candidate for total hip replacement; AND
    • Is likely to outlive a traditional prosthesis; AND
    • The member 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.
3. All other types and applications of hip resurfacing are considered investigational.


Medicare Coverage:
There is no National Coverage Determination (NCD) or Local Coverage Determination (LCD) for jurisdiction JL for this service. Therefore, Medicare Advantage Products will follow the Horizon BCBSNJ Medical Policy.

Medicaid Coverage:
For members enrolled in Medicaid and NJ FamilyCare plans, Horizon BCBSNJ applies the above medical policy.

FIDE-SNP:
For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.


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Horizon BCBSNJ Medical Policy Development Process:

This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.

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Index:
Hip Resurfacing
Partial Hip Resurfacing
Resurfacing, Total Hip
Total Hip Resurfacing
Birmingham Hip Resurfacing System
Buechel-Pappas Integrated Total Hip Replacement
Conserve Plus
Cormet Hip Resurfacing System
Surface Hip Arthroplasty

References:

1. Blue Cross and Blue Shield Association Technology Evaluation Center. Metal-on-metal total hip resurfacing. TEC Assessments. 2007;Vol 22:Tab 3.

2. Vendittoli PA, Lavigne M, Roy AG, et al. A prospective randomized clinical trial comparing metal-on-metal total hip arthroplasty and metal-on-metal total hip resurfacing in patients less than 65 years old. Hip Int. Jan 2006;16(Suppl 4):73-81. PMID 19219833

3. Food and Drug Administration. P040033: Birmingham Hip Resurfacing (BHR) System. 2006; http://www.accessdata.fda.gov/cdrh_docs/pdf4/p040033a.pdf. Accessed March 5, 2020.

4. Australian Orthopedic Association. National Joint Replacement Registry Annual Report. Adelaide, Australia: AOA; 2006.

5. Nunley RM, Della Valle CJ, Barrack RL. Is patient selection important for hip resurfacing? Clin Orthop Relat Res. Jan 2009;467(1):56-65. PMID 18941859

6. Marker DR, Strimbu K, McGrath MS, et al. Resurfacing versus conventional total hip arthroplasty - review of comparative clinical and basic science studies. Bull NYU Hosp Jt Dis. Jul 2009;67(2):120-127. PMID 19583538

7. Jiang Y, Zhang K, Die J, et al. A systematic review of modern metal-on-metal total hip resurfacing vs standard total hip arthroplasty in active young patients. J Arthroplasty. Apr 2011;26(3):419-426. PMID 20851564

8. Quesada MJ, Marker DR, Mont MA. Metal-on-metal hip resurfacing: advantages and disadvantages. J Arthroplasty. Oct 2008;23(7 Suppl):69-73. PMID 18922377

9. Haddad FS, Konan S, Tahmassebi J. A prospective comparative study of cementless total hip arthroplasty and hip resurfacing in patients under the age of 55 years: a ten-year follow-up. Bone Joint J. May 2015;97-B(5):617- 622. PMID 25922454

10. Mont MA, Seyler TM, Ragland PS, et al. Gait analysis of patients with resurfacing hip arthroplasty compared with hip osteoarthritis and standard total hip arthroplasty. J Arthroplasty. Jan 2007;22(1):100-108. PMID 17197316

11. Lavigne M, Therrien M, Nantel J, et al. The John Charnley Award: The functional outcome of hip resurfacing and large-head THA is the same: a randomized, double-blind study. Clin Orthop Relat Res. Feb 2010;468(2):326- 336. PMID 19543863

12. Garbuz DS, Tanzer M, Greidanus NV, et al. The John Charnley Award: Metal-on-metal hip resurfacing versus large-diameter head metal-on-metal total hip arthroplasty: a randomized clinical trial. Clin Orthop Relat Res. Feb 2010;468(2):318-325. PMID 19697090

13. Azam MQ, McMahon S, Hawdon G, et al. Survivorship and clinical outcome of Birmingham hip resurfacing: a minimum ten years' follow-up. Int Orthop. Jan 2016;40(1):1-7. PMID 25820838

14. Daniel J, Pradhan C, Ziaee H, et al. Results of Birmingham hip resurfacing at 12 to 15 years: a single-surgeon series. Bone Joint J. Oct 2014;96-B(10):1298-1306. PMID 25274912

15. Murray DW, Grammatopoulos G, Pandit H, et al. The ten-year survival of the Birmingham hip resurfacing: an independent series. J Bone Joint Surg Br. Sep 2012;94(9):1180-1186. PMID 22933488

16. Matharu GS, McBryde CW, Pynsent WB, et al. The outcome of the Birmingham Hip Resurfacing in patients aged < 50 years up to 14 years post-operatively. Bone Joint J. Sep 2013;95-B(9):1172-1177. PMID 23997127

17. Pailhe R, Matharu GS, Sharma A, et al. Survival and functional outcome of the Birmingham Hip Resurfacing system in patients aged 65 and older at up to ten years of follow-up. Int Orthop. Jun 2014;38(6):1139-1145. PMID 24370976

18. Amstutz HC, Le Duff MJ, Campbell PA, et al. Clinical and radiographic results of metal-on-metal hip resurfacing with a minimum ten-year follow-up. J Bone Joint Surg Am. Nov 2010;92(16):2663-2671. PMID 21084576

19. Kim PR, Beaule PE, Laflamme GY, et al. Causes of early failure in a multicenter clinical trial of hip resurfacing. J Arthroplasty. Sep 2008;23(6 Suppl 1):44-49. PMID 18722302

20. Nunley RM, Zhu J, Brooks PJ, et al. The learning curve for adopting hip resurfacing among hip specialists. Clin Orthop Relat Res. Feb 2010;468(2):382-391. PMID 19779950

21. Gross TP, Liu F, Webb LA. Clinical outcome of the metal-on-metal hybrid Corin Cormet 2000 Hip Resurfacing System: an up to 11-year follow-up study. J Arthroplasty. Apr 2012;27(4):533-538 e531. PMID 21908168

22. McGrath MS, Marker DR, Seyler TM, et al. Surface replacement is comparable to primary total hip arthroplasty. Clin Orthop Relat Res. Jan 2009;467(1):94-100. PMID 18797977

23. Ball ST, Le Duff MJ, Amstutz HC. Early results of conversion of a failed femoral component in hip resurfacing arthroplasty. J Bone Joint Surg Am. Apr 2007;89(4):735-741. PMID 17403794

24. de Steiger RN, Miller LN, Prosser GH, et al. Poor outcome of revised resurfacing hip arthroplasty. Acta Orthop. Feb 2010;81(1):72-76. PMID 20170416

25. Reito A, Puolakka T, Elo P, et al. Outcome of Birmingham hip resurfacing at ten years: role of routine whole blood metal ion measurements in screening for pseudotumours. Int Orthop. Nov 2014;38(11):2251-2257. PMID 25030963

26. Williams DH, Greidanus NV, Masri BA, et al. Prevalence of pseudotumor in asymptomatic patients after metal- on-metal hip arthroplasty. J Bone Joint Surg Am. Dec 7 2011;93(23):2164-2171. PMID 22159851

27. Kwon YM, Ostlere SJ, McLardy-Smith P, et al. Asymptomatic pseudotumors after metal-on-metal hip resurfacing arthroplasty: prevalence and metal ion study. J Arthroplasty. Jun 2011;26(4):511-518. PMID 20591612

28. Steffen RT, Pandit HP, Palan J, et al. The five-year results of the Birmingham Hip Resurfacing arthroplasty: an independent series. J Bone Joint Surg Br. Apr 2008;90(4):436-441. PMID 18378915

29. Ollivere B, Darrah C, Barker T, et al. Early clinical failure of the Birmingham metal-on-metal hip resurfacing is associated with metallosis and soft-tissue necrosis. J Bone Joint Surg Br. Aug 2009;91(8):1025-1030. PMID 19651828

30. Mont MA, Seyler TM, Ulrich SD, et al. Effect of changing indications and techniques on total hip resurfacing. Clin Orthop Relat Res. Dec 2007;465:63-70. PMID 17891034

31. Grecula MJ. Resurfacing arthroplasty in osteonecrosis of the hip. Orthop Clin North Am. Apr 2005;36(2):231-242, x. PMID 15833461

32. Stulberg BN, Fitts SM, Zadzilka JD, et al. Resurfacing arthroplasty for patients with osteonecrosis. Bull NYU Hosp Jt Dis. Jul 2009;67(2):138-141. PMID 19583542

33. Beaule PE, Amstutz HC, Le Duff M, et al. Surface arthroplasty for osteonecrosis of the hip: hemiresurfacing versus metal-on-metal hybrid resurfacing. J Arthroplasty. Dec 2004;19(8 Suppl 3):54-58. PMID 15578554

34. Lombardi AV, Jr., Barrack RL, Berend KR, et al. The Hip Society: algorithmic approach to diagnosis and management of metal-on-metal arthroplasty. J Bone Joint Surg Br. Nov 2012;94(11 Suppl A):14-18. PMID 23118373

35. Walsh J. Metal on metal hip resurfacing as an alternative to total hip arthroscopy. California Technology Assessment Forum. October 19, 2011. http://icer-review.org/wp-content/uploads/2016/01/1375_file_MOM_Hip_2011_W.pdf. Accessed March 5, 2020.

36. McGrory B, Barrack R, Lachiewicz PF, et al. Modern metal-on-metal hip resurfacing. J Am Acad Orthop Surg. May 2010;18(5):306-314. PMID 20435881

37. National Institute for Health and Care Excellence (NICE). Total hip replacement and resurfacing arthroplasty for end-stage arthritis of the hip [TA304]. 2014; https://www.nice.org.uk/guidance/ta304. Accessed March 5, 2020.


Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)

CPT*
    27299
HCPCS
    S2118

* CPT only copyright 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
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Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.

The Horizon BCBSNJ Medical Policy Manual is proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this Medical Policy are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this Medical Policy may be updated or changed without notice, unless otherwise required by law and/or regulation. However, benefit determinations are made in the context of medical policies existing at the time of the decision and are not subject to later revision as the result of a change in medical policy

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