Humana Hip Arthroplasty Form

Description

Total hip arthroplasty (THA) is a surgical technique which involves the removal of the damaged articular surfaces on the hip which are then replaced with an artificial prosthesis consisting of acetabular, bearing surface or liner and femoral components. A metal stem is placed into the hollow center of the femur replacing the damaged femoral head. The femoral stem may be either cemented or press fit into the bone. A metal or ceramic ball is placed on the upper part of the stem to replace the damaged femoral head (the ball) that was removed. The damaged cartilage surface of the socket (acetabulum) is removed and replaced with a metal socket. A plastic or ceramic liner is inserted between the new prosthetic ball and socket to allow for a smooth gliding surface.

Partial hip replacement, also called hip hemiarthroplasty, is a surgical technique where only the femoral head of the damaged hip joint is replaced. The acetabulum or hip socket is not replaced. The prostheses may be unipolar or bipolar. A unipolar prosthesis has a one piece fixed head design where the hip movement occurs between the prosthesis and the acetabulum. A bipolar prosthesis has an additional artificial joint or bearing between the stem and head component of the prosthesis that swivels during movement helping to reduce the amount of wear and tear on the new joint.

Hip resurfacing arthroplasty (HRA), also known as metal on metal (MOM) hip resurfacing and hemiresurfacing arthroplasty, may be considered as an alternative to conventional total hip arthroplasty. HRA does not remove the femoral head and neck, or bone from the femur allowing for conversion to a THA, when necessary. The resurfacing procedure is designed for a younger, active individual (typically less than 65 years of age) with viable bone in the proximal femur who is likely to outlive the prosthesis used in the THA procedure.

Hip resurfacing arthroplasty can either be categorized as a partial (hemi) or total resurfacing:

• Partial HRA is the removal of the damaged surface of the femoral head, which is then resurfaced with a metal shell. The socket is left intact.
• Total HRA involves both the femoral shell and the acetabulum (socket) cup. A metal shell is placed over the head of the femur as in a partial HRA; however, the damaged surface of the hip socket is also resurfaced.

An example of US Food & Drug Administration (FDA) approved hip resurfacing system includes, but may not be limited to, the Birmingham hip resurfacing system and the Cormet hip resurfacing system.

Coverage Determination

Total Hip Arthroplasty Humana members may be eligible under the Plan for total hip arthroplasty when all of the following criteria are met:

• Absence of contraindications; AND
• Documentation of skeletal maturity*; AND

Hip Arthroplasty Effective Date: 11/2/2023 Revision Date: 11/2/2023 Review Date: 11/2/2023 Policy Number: HUM-0593-005 Page: 3 of 15

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

• Individual who is a smoker or nicotine user is provided assistance in developing a plan for quitting (cessation) that includes pharmacotherapy (eg, bupropion, varenicline) and/or referral to a smoking cessation program prior to the surgical procedure; AND
• The device is FDA-approved; AND any of the following:
• Documentation of painful, disabling joint disease of the hip that interferes with activities of daily living (ADLs) resulting from noninflammatory joint disease (avascular necrosis, osteoarthritis or post traumatic arthritis) or inflammatory arthritis (eg, rheumatoid arthritis) including:
  • Failure of 3 months of conservative treatment under the direction of a healthcare professional with ALL of the following:
    • Activity/lifestyle modifications; AND
    • Ambulatory assistive device if medically appropriate; AND
    • Individual with a BMI greater than 40 has documentation of attempted weight loss; AND
    • Intra-articular steroid injection if medically appropriate and not contraindicated. Intra-articular steroid injections should be avoided three months prior to planned THA; AND
    • Nonsteroidal anti-inflammatory drugs (NSAIDs) if medically appropriate and not contraindicated; AND
    • Physical therapy with home exercise program (HEP) (for information regarding coverage determination/ limitations, please refer to Physical Therapy and Occupational Therapy Medical Coverage Policy); OR
  • Acetabular fracture; OR
  • Fracture of the femoral neck; OR
  • Hemophilic arthropathy with contracture in the hip; OR
  • Malignancy of the joint involving the bones or soft tissues of the pelvis or proximal femur; OR
  • Malunion of acetabular or proximal femur fracture; OR
  • Nonunion or failure of previous hip fracture surgery; OR
  • Radiographic confirmation of avascular necrosis with stage III collapse of the femoral head; OR
  • Radiographic confirmation of Kellgren Lawrence grade 4 pathology of the hip joint);

*Skeletally mature refers to a system of fused skeletal bones which occurs when bone growth ceases.

Coverage Limitations

Total Hip Arthroplasty Humana members may NOT be eligible under the Plan for a total hip arthroplasty for any indications other than those listed above including, but may not be limited to, the following contraindications:

• Active infections of the body or blood such as sepsis; OR
• Allergy to components of the implant (eg, alumina, chromium or cobalt); OR
• Charcot joint; OR
• Inadequate bone stock that would not support implant unless the procedure is for a fracture indication; OR
• Multiple uncontrolled comorbid medical conditions (eg, diabetes); OR

Hip Arthroplasty Effective Date: 11/2/2023 Revision Date: 11/2/2023 Review Date: 11/2/2023 Policy Number: HUM-0593-005 Page: 5 of 15

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

• Paraplegia or quadriplegia; OR
• Rapidly progressive neurological disease except in the clinical situation of a concomitant displaced femoral neck; OR
• Skeletal immaturity; OR
• Suppressed immune system due to disease or high doses of corticosteroids; OR
• Vascular insufficiency or significant muscular atrophy of the leg or neuromuscular disease severe enough to compromise implant stability or postoperative recovery

These are considered experimental/investigational as they are not identified as widely used and generally accepted for any other proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.

Coverage Determination

Partial Hip Arthroplasty Humana members may be eligible under the Plan for partial hip arthroplasty for the following indications:

• Absence of contraindications; AND
• Acetabulum is intact; AND
• 65 years of age or older; AND
• The device is FDA-approved; AND
• Femoral neck fracture when surgical fixation is not considered a reasonable option

Hip Arthroplasty Effective Date: 11/2/2023 Revision Date: 11/2/2023 Review Date: 11/2/2023 Policy Number: HUM-0593-005 Page: 6 of 15

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Coverage Limitations

Partial Hip Arthroplasty Humana members may NOT be eligible under the Plan for a partial hip arthroplasty for any indications other than those listed above including, but may not be limited to, the following contraindications:

• Active infections (local or systemic); OR
• Allergy to components of the implant (e.g., alumina, chromium or cobalt); OR
• BMI greater than 40; OR
• Charcot joint; OR
• Inadequate bone stock that would not support implant unless the procedure is for a fracture indication; OR
• Inflammatory arthropathy (e.g., rheumatoid arthritis); OR
• Multiple uncontrolled comorbid medical conditions (e.g., diabetes); OR
• Noninflammatory arthropathy (e.g., avascular necrosis, osteoarthritis or post traumatic arthritis); OR
• Suppressed immune system due to disease or high doses of corticosteroids; OR
• Vascular insufficiency, significant muscular atrophy of the leg or neuromuscular disease severe enough to compromise implant stability or postoperative recovery

This is considered experimental/investigational as it is not identified as widely used and generally accepted for any other proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.

Coverage Determination

Hip Resurfacing Arthroplasty Humana members may be eligible under the Plan for partial or total hip resurfacing arthroplasty for the following indications:

Hip Arthroplasty Effective Date: 11/2/2023 Revision Date: 11/2/2023 Review Date: 11/2/2023 Policy Number: HUM-0593-005 Page: 7 of 15

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

• Absence of contraindications; AND
• Documentation of skeletal maturity*; AND
• Failure of 3 months of conservative treatment under the direction of a healthcare professional with ALL of the following:
  • Activity/lifestyle modifications; AND
  • Ambulatory assistive device if medically appropriate; AND
  • Intra-articular steroid injection if medically appropriate and not contraindicated. Intra-articular steroid injections should be avoided three months prior to partial or total hip resurfacing arthroplasty; AND
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) if medically appropriate and not contraindicated.

*Skeletally mature refers to a system of fused skeletal bones which occurs when bone growth ceases.

• Physical therapy with home exercise program (HEP) (for information regarding coverage determination/ limitations, please refer to Physical Therapy and Occupational Therapy Medical Coverage Policy); AND
• Individual who is a smoker or nicotine user is provided assistance in developing a plan for quitting (cessation) that includes pharmacotherapy (eg, bupropion, varenicline) and/or referral to a smoking cessation program prior to the surgical procedure; AND
• Normal proximal femoral bone geometry and bone quality; AND
• Physically active individual who is 65 years of age or younger; AND
• The device is FDA-approved; AND
• Individual who would otherwise receive a traditional primary THR, but is likely to live longer than the traditional device is expected to last;

Hip Arthroplasty Effective Date: 11/2/2023 Revision Date: 11/2/2023 Review Date: 11/2/2023 Policy Number: HUM-0593-005 Page: 8 of 15

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

AND any of the following:

• Avascular necrosis with less than 50 percent involvement of the femoral head; OR
• Dysplasia/developmental dislocation of the hip; OR
• Inflammatory arthritis (eg, rheumatoid arthritis); OR
• Noninflammatory degenerative joint disease (eg, osteoarthritis, traumatic arthritis)

*Skeletally mature refers to a system of fused skeletal bones which occurs when bone growth ceases.

Coverage Hip Resurfacing Arthroplasty

Coverage Limitations

Hip Resurfacing Arthroplasty Humana members may NOT be eligible under the Plan for a partial or total hip resurfacing arthroplasty for any indications other than those listed above including, but may not be limited to, the following contraindications:

• Active infection (local or systemic); OR
• Allergy to components of the implant (eg, alumina, chromium or cobalt); OR
• Bone stock inadequate to support the device due to conditions such as osteoporosis, osteonecrosis or avascular necrosis with greater than 50 percent involvement of the femoral head or fluid-filled cavities greater than one centimeter in the femoral head; OR
• BMI greater than 40; OR
• Implants which are metal-on-polyethylene; OR
• Inactive and/or older individual who may be unlikely to require revision of a traditional THA; OR

Hip Arthroplasty Effective Date: 11/2/2023 Revision Date: 11/2/2023 Review Date: 11/2/2023 Policy Number: HUM-0593-005 Page: 9 of 15

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

• Female of childbearing age since it is unknown whether metal ions released by the device could harm an unborn child; OR
• Multiple uncontrolled comorbid medical conditions; OR
• Significantly impaired function of the kidneys (glomerular filtration rate [GFR] less than 60 mL/min/1.73 m2); OR
• Skeletal immaturity; OR
• Suppressed immune system due to disease or high doses of corticosteroids; OR
• Vascular insufficiency, significant muscular atrophy of the leg or neuromuscular disease severe enough to compromise implant stability or postoperative recovery

This is considered experimental/investigational as it is not identified as widely used and generally accepted for any other proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.

Coverage Determination

Revision/Replacement of Hip Resurfacing Arthroplasty, Partial Hip Arthroplasty, Total Hip Arthroplasty Humana members may be eligible under the Plan for replacement or revision of previous total, partial or resurfacing hip arthroplasty for the following indications:

• Absence of multiple uncontrolled comorbid medical conditions (eg, diabetes); AND
• Individual who is a smoker or nicotine user is provided assistance in developing a plan for quitting (cessation) that includes pharmacotherapy (eg, bupropion, varenicline) and/or referral to a smoking cessation program prior to the surgical procedure; AND
• AND any of the following:
  • Aseptic loosening of prosthesis; OR
  • Bearing surface wear leading to symptomatic synovitis or local bone or soft tissue reaction; OR
  • Fracture or mechanical failure of implant; OR
  • Leg length discrepancy when source is mechanical and correctable by surgery; OR
  • Periprosthetic fracture; OR
  • Periprosthetic infection; OR
  • Recurrent prosthetic dislocation not responsive to a reasonable course of nonsurgical care (closed reduction); OR
  • Tissue or systemic reaction to metal implant

Hip Arthroplasty Effective Date: 11/2/2023 Revision Date: 11/2/2023 Review Date: 11/2/2023 Policy Number: HUM-0593-005 Page: 10 of 15

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Additional information about osteoarthritis and rheumatoid arthritis may be found from the following websites:

Background

• American Academy of Orthopaedic Surgeons
• National Institute of Arthritis and Musculoskeletal and Skin Disease
• National Library of Medicine

Medical Alternatives

Physician consultation is advised to make an informed decision based on an individual’s health needs.

Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.