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Date Printed: June 26, 2017: 01:08 AM

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02-20000-50

Original Effective Date: 10/15/16

Reviewed: 03/23/17

Revised: 04/15/17

Subject: Hip Arthroplasty

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

Arthroplasty describes the surgical replacement or reconstruction of a joint with implanted devices when the joint has been damaged by an arthritic, traumatic, or malignant process. Patients with advanced arthritis of the hip may be candidates for either traditional total hip replacement (arthroplasty) or hip resurfacing (hip resurfacing arthroplasty). Each of these procedures is a type of hip replacement.

Total hip arthroplasty describes the reconstruction of the entire joint articular surfaces, including the femoral head and acetabular sides. Hip resurfacing arthroplasty replaces the articular surface of the femoral head with limited removal of femoral bone and the entire surface of the acetabulum. Revision/conversion hip arthroplasty describes surgical reconstruction due to failure or complication of a previous arthroplasty or reconstruction.

Elective arthroplasty surgery may be considered when pain and documented loss of function cause a diminished quality of life.

POSITION STATEMENT:

Total Hip Arthroplasty (THA)

Total hip arthroplasty meets the definition of medical necessity for the following:

• When hip pathology is present and due to one of the following, as confirmed by imaging:

• Rheumatoid arthritis

• Femoral neck fracture in the setting of pre-existing arthritis, malignancy, or failure of previous surgery

• Dysplasia

• Avascular necrosis with collapse, confirmed by imaging, AND

• There are no relative or absolute contraindications to hip arthroplasty (e.g., allergy to implant metal selected, chronic renal insufficiency, local active infection, female of child-bearing age)

OR

• When hip pathology is present and ALL of the following are met:

• Pain and documented loss of function have been present for at least 6 months (deviation from normal hip function, which may include painful weight bearing; painful or inadequate range of motion to accomplish activities of daily living (ADLs), recreational activity, and/or employment; mechanical catching, locking, popping)

Three (3) months of non-operative management* have failed to improve symptoms

• Physical exam has typical findings of hip pathology as evidenced by one or more of the following:

• Painful, limited range of motion or antalgic gait

• Contracture

• Crepitus

• Leg length difference

• Imaging demonstrates advanced hip joint arthritis of at least Kellgren-Lawrence** grade 3 to 4, OR Tönnis*** grade 2 or 3

No injection into the joint within 3 months of surgery, AND

• There are no relative or absolute contraindications to hip arthroplasty (e.g., allergy to implant metal selected, chronic renal insufficiency, local active infection, female of child-bearing age)

Hip Resurfacing Arthroplasty

Hip resurfacing arthroplasty meets the definition of medical necessity when ALL of the following are met:

• Pain and documented loss of function have been present for at least 6 months (deviation from normal hip function, which may include painful weight bearing; painful or inadequate range of motion to accomplish activities of daily living (ADLs), recreational activity, and/or employment; or mechanical catching, locking, popping)

• Six (6) months of non-operative management* have failed to improve symptoms

• Physical exam has typical findings of hip pathology as evidenced by one or more of the following:

• Painful, limited range of motion or antalgic gait

• Contracture

• Crepitus

• Leg length difference

• Imaging demonstrates advanced hip joint pathology of at least Kellgren-Lawrence** grade 3 to 4, or Tönnis*** grade 2 or 3, or avascular necrosis involving less than 50% of the femoral head

• Male candidate is less than 65 years old, or female candidate is less than 55 years old

• BMI less than 40

No injection into the joint within 3 months of surgery, AND

• No evidence of any of the following contraindications:

• Osteoporosis or osteopenia (documented by DEXA scan bone mineral density evaluation)

• Other co-morbidity that may contribute to active bone demineralization (including medications that contribute to decreased bone mineral density (glucocorticoid steroids, heparin, aromatase inhibitors, thiazolidinediones, proton pump inhibitors, loop diuretics, cyclosporine, anti-retrovirals, anti-psychotics, anti-seizures, certain breast cancer drugs, certain prostate cancer drugs, depo-provera, aluminum-containing antacids)

• Cystic degeneration at the junction of the femoral head and neck on radiographs or MRI or CT

• Malignancy at the proximal femur

• Current or recent hip infection, or sepsis

• Female of child-bearing age

• Chronic renal insufficiency

• Metal allergy

Hip Revision/Conversion Arthroplasty

Hip revision/conversion arthroplasty meets the definition of medical necessity for the following indications:

• There is extensive disease or damage following a previous hip reconstruction, due to fracture, malignancy, osteolysis, or other bone or soft-tissue reactive or destructive process, confirmed by MRI or other advanced imaging, OR

• There is an infected joint following a previous hip reconstruction, confirmed by synovial fluid aspiration (cell count and/or culture), OR

• When ALL of the following are present:

• Symptomatic hip arthroplasty where patient has persistent, severe disabling pain and loss of function for more than 6 months, AND

• Unstable joint upon physical exam, AND

• At least one of the following:

• Aseptic loosening, osteolysis

• Other bone or soft-tissue reactive or destructive process

• Inappropriate positioning of components

• Other failure of fixation of components confirmed on imaging

Procedures utilizing patient-specific or gender-specific instrumentation is considered experimental or investigational. Procedures using computer-navigated instrumentation is considered experimental or investigational. (see MCG 02-20000-30, Computer Assisted Musculoskeletal Surgical Navigational Orthopedic Procedure) There is a lack of clinical scientific evidence published in peer-reviewed literature to permit conclusions on safety and net health outcomes.

*Non-operative management may include one or more of the following modalities:

• Rest or activity modifications/limitations

• Weight reduction for patient with elevated BMI

• Protected weight-bearing with cane, walker or crutches

• Physical therapy modalities

• Supervised home exercise

• Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, analgesics

• Injections (e.g., cortisone)

**Kellgren-Lawrence Grading System:

Grade 0: No radiographic features of osteoarthritis

Grade 1: Possible joint space narrowing and osteophyte formation

Grade 2: Definite osteophyte formation with possible joint space narrowing

Grade 3: Moderate multiple osteophytes, definite narrowing of joint space, some sclerosis and possible deformity of bone contour (some sclerosis and cyst formation and deformity of femoral head and acetabulum)

Grade 4: Large osteophytes, marked narrowing of joint space, severe sclerosis and definite deformity of bone contour (increased deformity of the femoral head and acetabulum)

***Tönnis Classification of Osteoarthritis by Radiographic Changes

0: No signs of osteoarthritis

1: Mild: Increased sclerosis, slight narrowing of the joint space, no or slight loss of head sphericity

2: Moderate: Small cysts, moderate narrowing of the joint space, moderate loss of head sphericity

3: Severe: Large cysts, severe narrowing or obliteration of the joint space, severe deformity of the head

BILLING/CODING INFORMATION:

CPT Coding

27130

Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft

27132

Conversion of previous hip surgery to total hip arthroplasty, with or without autograft or allograft

27134

Revision of total hip arthroplasty; both components, with or without autograft or allograft

27137

Revision of total hip arthroplasty; acetabular component only, with or without autograft or allograft

27138

Revision of total hip arthroplasty; acetabular component only, with or without autograft or allograft

HCPCS Coding

S2118

Metal-on-metal total hip resurfacing, including acetabular and femoral components

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products: The following Local Coverage Determination (LCD) was reviewed on the last guideline review date: Major Joint Replacement (Hip and Knee) (L33618), located at fcso.com.

DEFINITIONS:

No guideline specific definitions apply.

RELATED GUIDELINES:

Femoroacetabular Impingement (FAI) Syndrome Surgery (Open or Arthroscopic), 02-20000-35

Hip Arthroscopy and Open, Non-Arthroplasty Hip Repair, 02-20000-55

Computer-Assisted Navigation for Orthopedic Procedures, 02-20000-30

OTHER:

None applicable.

REFERENCES:

  1. AHRQ National Guideline Clearinghouse. NGC10528: American Academy of Orthopaedic Surgeons clinical practice guideline on management of hip fractures in the elderly. September 2014.
  2. American Academy of Orthopaedic Surgeons (AAOS). Guideline and Evidence Report. The treatment of glenohumeral joint osteoarthritis. Accessed at http://www.orthoguidelines.org/guideline-detail?id=1156.
  3. American Academy of Orthopaedic Surgeons (AAOS). OrthoInfo. Hip Resurfacing. Accessed at http://orthoinfo.aaos.org/topic.cfm?topic=A00586.
  4. Bergh C, et al. Increased risk of revision in patients with non-traumatic femoral head necrosis: 11,589 cases compared to 416,217 cases with primary osteoarthritis in the NARA database, 1995-2011. Acta orthopaedica 85.1 (2014): 11-17.
  5. Blue Cross Blue Shield Association Medical Policy Reference Manua. 7.01.80, Hip Resurfacing. September 2015.
  6. Fernandes L, et al. EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis. Annals of the rheumatic diseases 72.7 (2013): 1125-1135.
  7. First Coast Service Options (FCSO). Local Coverage Determination (LCD): Major Joint Replacement (Hip and Knee) (L33618) (October 1, 2015).
  8. Ghomrawi HMK, et al. Appropriateness criteria and elective procedures—total joint arthroplasty. New England Journal of Medicine 367.26 (2012): 2467-2469.
  9. Gossec L., et al. The role of pain and functional impairment in the decision to recommend total joint replacement in hip and knee osteoarthritis: an international cross-sectional study of 1909 patients. Report of the OARSI-OMERACT Task Force on total joint replacement. Osteoarthritis and Cartilage 19.2 (2011): 147-154.
  10. Hochberg MC, et al. American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis care & research 64.4 (2012): 465-474.
  11. InterQual® 2014. CP: Procedures, Adult. Removal and Replacement, Total Joint Replacement (TJR), Hip.
  12. InterQual® 2014. CP: Procedures, Adult. Total Joint Replacement (TJR), Hip.
  13. National Imaging Associates, Inc. Hip Arthroplasty, Total and Revision/Conversion Clinical Guideline, 2016.
  14. National Imaging Associates, Inc. Hip Arthroplasty, Total and Revision/Conversion Clinical Guideline, 2017.
  15. National Institute for Health and Care Excellence (NICE). NICE technology appraisal guidance [TA304]: Total hip replacement and resurfacing arthroplasty for end-stage arthritis of the hip. February 2014. Accessed at https://www.nice.org.uk/guidance/ta304.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 03/23/17.

GUIDELINE UPDATE INFORMATION:

10/15/16

New Medical Coverage Guideline.

04/15/17

Revision: updated criteria for total hip arthroplasty and hip resurfacing arthroplasty. Added coverage statement (E/I) for patient-specific, gender-specific, and computer-navigated instrumentation. Updated references.

Date Printed: June 26, 2017: 01:08 AM