HIP REPLACEMENT SURGERY (ARTHROPLASTY)

Transcription

1 Prtcl: ORT015 Effective Date: June 1, 2017 HIP REPLACEMENT SURGERY (ARTHROPLASTY) Table f Cntents Page COMMERCIAL & MEDICAID COVERAGE RATIONALE... 1 MEDICARE COVERAGE RATIONALE... 3 U.S.FOOD AND DRUG ADMINISTRATION (FDA)... 4 APPLICABLE CODES... 5 PROTOCOL HISTORY/REVISION INFORMATION... 5 INSTRUCTIONS FOR USE This prtcl prvides assistance in interpreting UnitedHealthcare benefit plans. When deciding cverage, the enrllee specific dcument must be referenced. The terms f an enrllee's dcument (e.g., Certificate f Cverage (COC) r Evidence f Cverage (EOC)) may differ greatly. In the event f a cnflict, the enrllee's specific benefit dcument supersedes this prtcl. All reviewers must first identify enrllee eligibility, any federal r state regulatry requirements and the plan benefit cverage prir t use f this Prtcl. Other Prtcls, Plicies and Cverage Determinatin Guidelines may apply. UnitedHealthcare reserves the right, in its sle discretin, t mdify its Prtcls, Plicies and Guidelines as necessary. This prtcl is prvided fr infrmatinal purpses. It des nt cnstitute medical advice. This plicy des nt gvern Medicare Grup Retiree members. UnitedHealthcare may als use tls develped by third parties, such as the MCG Care Guidelines, t assist us in administering health benefits. The MCG Care Guidelines are intended t be used in cnnectin with the independent prfessinal medical judgment f a qualified health care prvider and d nt cnstitute the practice f medicine r medical advice. COMMERCIAL & MEDICAID COVERAGE RATIONALE Fr infrmatin regarding medical necessity review, when applicable, see MCG Care Guidelines, 21st Editin, 2017Hip Arthrplasty, S-560 (ISC), accessed April MCG Care Guidelines: Hip Arthrplasty, S-560 Clinical Indicatins fr Prcedure: Prcedure is indicated fr 1 r mre f the fllwing: Degenerative jint disease as indicated by ALL f the fllwing: Presence f significant radigraphic findings (eg, hip jint destructin, severe narrwing, bne defrmities, stenecrsis) Optimal medical management has been tried and failed (eg, analgesics, NSAIDs, physical therapy) Patient has failed r is nt a candidate fr mre cnservative measures (eg, stetmy, hemiarthrplasty) Hip Replacement Surgery (Arthrplasty) Page 1 f 6

2 Treatment is needed because f 1 r mre f the fllwing: Disabling pain Functinal disability Primary and secndary tumrs invlving the prximal femur Ostenecrsis f femral head Develpmental dysplasia f hip Displaced fracture f the femral neck in a patient withut significant cgnitive impairment Acetabular fracture Pertrchanteric fracture and 1 r mre f the fllwing: Ipsilateral hip stearthritis Ipsilateral avascular necrsis f the femral head Inflammatry arthritis Cmminuted, significantly displaced, r unstable fracture Pr bne quality (eg, thin crtices, wide intramedullary canal n imaging) Cmplicatin f internal fixatin Neglected fracture Failed previus hip fracture fixatin Revisin f hip arthrdesis Revisin f previus arthrplasty r resurfacing indicated by 1 r mre f the fllwing: Instability f ne r bth cmpnents Fracture r mechanical failure f the implant Recurrent r irreducible dislcatin Infectin Treatment f a periprsthetic fracture Tissue r systemic reactin t metal implant Leg-length inequality **End f MCG Fr infrmatin regarding medical necessity review, when applicable, see MCG Care Guidelines, 21st Editin, 2017, Hip: Displaced Fracture f Femral Neck, Hemiarthrplasty, S-600 (ISC), accessed April MCG Care Guidelines: Hip: Displaced Fracture f Femral Neck, Hemiarthrplasty, S-600 (ISC) Clinical Indicatins fr Prcedure Prcedure is indicated fr 1 r mre f the fllwing: Displaced fracture f femral neck in lder patient (eg, 65 years r lder) Fracture-dislcatin f hip in lder patient (eg, 65 years r lder) Reductin r fixatin f hip fracture that cannt be maintained Recent histry f failed fixatin f femral neck fracture Fracture f neck f femur with cmplete dislcatin f femral head Fracture superimpsed upn pre-existing lesins f hip (eg, radiatin changes, severe arthritis) Fracture f femral neck in patient with psychsis r severe cgnitive impairment Pathlgic fracture f femral neck Pertrchanteric fracture and 1 r mre f the fllwing: Hip Replacement Surgery (Arthrplasty) Page 2 f 6

3 Ipsilateral hip stearthritis Ipsilateral avascular necrsis f the femral head Inflammatry arthritis Cmminuted, significantly displaced, r unstable fracture Pr bne quality (eg, thin crtices, wide intramedullary canal n imaging) Cmplicatin f internal fixatin Neglected fracture ***End f MCG MEDICARE COVERAGE RATIONALE Medicare des nt have a Natinal Cverage Determinatin, but des have a Lcal Cverage Determinatin fr Nevada fr Ttal Jint Arthrplasty (L34163) (Accessed April 2017). Ttal Jint Arthrplasty (L34163) Ttal Hip Arthrplasty (THA) Ttal hip replacement surgery is medically necessary when ne r mre f the fllwing criteria* are met: Advanced jint disease demnstrated by: Radigraphic supprted evidence r when cnventinal radigraphy is nt adequate, magnetic resnance imaging (MRI) supprted evidence (subchndral cysts, subchndral sclersis, periarticular stephytes, jint subluxatin, jint space narrwing, avascular necrsis); and Pain that cannt be adequately cntrlled despite ptimal cnservative treatment r functinal disability frm injury due t trauma r arthritis f the jint); and If apprpriate, histry f unsuccessful cnservative therapy (nn-surgical medical management) that is clearly addressed in the pre prcedure medical recrd. (If cnservative therapy is nt apprpriate, the medical recrd must clearly dcument the ratinale fr why such apprach is nt reasnable); r Malignancy f the jint invlving the bnes r sft tissues f the pelvis r prximal femur; r Avascular necrsis (stenecrsis f femral head); r Fracture f the femral neck; r Acetabular fracture; r Nn-unin r failure f previus hip fracture surgery; r Mal-unin f acetabular r prximal femur fracture *See Assciated Infrmatin Dcumentatin Requirements fr additinal infrmatin. Nn-surgical medical management is usually but nt always implemented prir t scheduling ttal jint surgery. Nn-surgical treatment as clinically apprpriate fr the patient s current episde f care typically includes ne r mre f the fllwing: anti-inflammatry medicatins r analgesics, r flexibility and muscle strengthening exercises, r supervised physical therapy [Activities f daily living (ADLs) diminished despite cmpleting a plan f care], r assistive device use, r Hip Replacement Surgery (Arthrplasty) Page 3 f 6

4 weight reductin as apprpriate, r therapeutic injectins int the hip as apprpriate. Indicatins fr Replacement/Revisin f Ttal Hip Arthrplasty Lsening f ne r bth cmpnents; r Fracture r mechanical failure f the implant; r Recurrent r irreducible dislcatin; r Infectin; r Treatment f a displaced periprsthetic fracture; r Clinically significant leg length inequality nt amenable t cnservative management; r Prgressive r substantial bne lss; r Bearing surface wear leading t symptmatic synvitis r lcal bne r sft tissue reactin; r Clinically significant audible nise; r Adverse lcal tissue reactin Limitatins Ttal knee replacement r ttal hip replacement is nt medically necessary when the fllwing cntraindicatins are present: Active infectin f the hip r knee jint r active systemic bacteremia Active skin infectin (exceptin recurrent cutaneus staph infectins) r pen wund within the planned surgical site f the hip r knee Rapidly prgressive neurlgical disease except in the clinical situatin f a cncmitant displaced femral neck fracture The fllwing cnditins are relative cntraindicatins t ttal knee r ttal hip replacement and if such surgery is perfrmed in the presence f these cnditins, it is expected that the ratinale fr prceeding with the surgery under such circumstances is clearly dcumented in the medical recrd: Absence r relative insufficiency f abductr musculature Any prcess that is rapidly destrying bne Neurtrphic arthritis Fr Medicare and Medicaid Determinatins Related t States Outside f Nevada: Please review Lcal Cverage Determinatins that apply t ther states utside f Nevada. Imprtant Nte: Please als review lcal carrier Web sites in additin t the Medicare Cverage database n the Centers fr Medicare and Medicaid Services Website. U.S.FOOD AND DRUG ADMINISTRATION (FDA) Hip replacement surgery is a prcedure and therefre is nt regulated by the FDA. Hwever, devices and instruments used during the surgery require FDA apprval. Several devices have FDA apprval. Additinal infrmatin (prduct cde MEH, JDI, JDG, LWJ, LPH, LZO, KWY, KWA) is available at: Accessed April Hip Replacement Surgery (Arthrplasty) Page 4 f 6

5 The FDA-apprved ttal hip arthrplasty (THA) devices are generally apprved fr the same indicatins, including any r all f the fllwing: Severe hip pain and disability due t stearthritis (OA), rheumatid arthritis (RA), traumatic arthritis (TA), plyarthritis, cllagen disrders, avascular necrsis f the femral head, r nnunin f prir femral fracture. Cngenital hip dysplasia, prtrusia acetabuli (bulging f the femral head int the pelvis), r slipped capital femral epiphysis. Disability due t previus fusin. Acute femral neck fracture. APPLICABLE CODES The fllwing list(s) f prcedure and/r diagnsis cdes is prvided fr reference purpses nly and may nt be all inclusive. Listing f a cde in this plicy des nt imply that the service described by the cde is a cvered r nn- cvered health service. Benefit cverage fr health services is determined by the member specific benefit plan dcument and applicable laws that may require cverage fr a specific service. The inclusin f a cde des nt imply any right t reimbursement r guarantee claim payment. Other Plicies and Cverage Determinatin Guidelines may apply. CPT Cdes Descriptin Acetabulplasty; (e.g., Whitman, Clnna, Haygrves, r cup type) Acetabulplasty; resectin, femral head (e.g., Girdlestne prcedure) Hemiarthrplasty, hip, partial (e.g., femral stem prsthesis, biplar arthrplasty) Arthrplasty, acetabular and prximal femral prsthetic replacement (ttal hip arthrplasty), with r withut autgraft r allgraft Cnversin f previus hip surgery t ttal hip arthrplasty, with r withut autgraft r allgraft Revisin f ttal hip arthrplasty; bth cmpnents, with r withut autgraft r allgraft Revisin f ttal hip arthrplasty; acetabular cmpnent nly, with r withut autgraft r allgraft Hip Revisin f ttal hip arthrplasty; femral cmpnent nly, with r withut allgraft CPT is a registered trademark f the American Medical Assciatin PROTOCOL HISTORY/REVISION INFORMATION Date 04/27/ /28/ /25/ /25/ /22/ /19/ /28/2013 Actin/Descriptin Crprate Medical Affairs Cmmittee Hip Replacement Surgery (Arthrplasty) Page 5 f 6

6 04/26/ /23/2012 The freging Health Plan f Nevada/Sierra Health & Life Health Operatins prtcl has been adpted frm an existing UnitedHealthcare cverage determinatin guideline that was researched, develped and apprved by the UnitedHealthcare Cverage Determinatin Cmmittee. Hip Replacement Surgery (Arthrplasty) Page 6 f 6