clinical policy bulletin: total hip replacement - aetna · clinical policy bulletin: total hip...

15
Total Hip Replacement Page 1 of 15 http://qawww.aetna.com/cpb/medical/data/200_299/0287_draft.html 04/22/2015 Aetna Better Health® 2000 Market Street, Suite 850 Philadelphia, PA 19103 AETNA BETTER HEALTH® Clinical Policy Bulletin: Total Hip Replacement Number: 0287 Policy Aetna considers an Food and Drug Administration-approved metal-on-metal, metal -on-plastic, ceramic-on-plastic, or ceramic-on-ceramic total hip arthroplasty (THA) prosthesis medically necessary for adult members when the following criteria are met: I. Member has advanced joint disease demonstrated by: A. Pain and functional disability that interferes with activities of daily living (ADLs) from injury due to osteoarthritis, rheumatoid arthritis, avascular necrosis, or post-traumatic arthritis of the hip joint; and B. Limited range of motion (ROM), antalgic gait, and pain in hip joint with passive ROM on physical examination: and C. Radiographic evidence of severe osteoarthritis (as evidence by 2 or more of the following: subchondral cysts, subchondral sclerosis, periarticular osteophytes, joint subluxation, bone on bone articulation or joint space narrowing) of hip joint, or avascular necrosis (osteonecrosis) with stage III collapse of the femoral head, or rheumatoid arthritis (joint space narrowing); and D. History of of unsuccessful conservative therapy (non-surgical medical management) that is clearly addressed in the medical record (see Note). If conservative therapy is not appropriate, the medical record must clearly document why such approach is not reasonable; or II. III. IV. Fracture of the femoral neck by imaging with pain interfering with ADLs; or Malunion of acetabular, femoral head or proximal femur fracture with pain interfering with ADLs; or Nonunion by imaging or failure of previous hip fracture surgery with pain interfering with ADLs; or

Upload: phungquynh

Post on 02-Aug-2019

217 views

Category:

Documents


0 download

TRANSCRIPT

Page 1: Clinical Policy Bulletin: Total Hip Replacement - Aetna · Clinical Policy Bulletin: Total Hip Replacement Number: 0287 Policy Aetna considers an Food and Drug Administration-approved

Total Hip Replacement Page 1 of 15

http://qawww.aetna.com/cpb/medical/data/200_299/0287_draft.html 04/22/2015

Aetna Better Health® 2000 Market Street, Suite 850 Philadelphia, PA 19103

AETNA BETTER HEALTH®

Clinical Policy Bulletin: Total Hip Replacement

Number: 0287

Policy

Aetna considers an Food and Drug Administration-approved metal-on-metal, metal

-on-plastic, ceramic-on-plastic, or ceramic-on-ceramic total hip arthroplasty

(THA) prosthesis medically necessary for adult members when the following

criteria are met:

I. Member has advanced joint disease demonstrated by:

A. Pain and functional disability that interferes with activities of daily

living (ADLs) from injury due to osteoarthritis, rheumatoid

arthritis, avascular necrosis, or post-traumatic arthritis of the hip

joint; and

B. Limited range of motion (ROM), antalgic gait, and pain in hip joint

with passive ROM on physical examination: and

C. Radiographic evidence of severe osteoarthritis (as evidence by 2 or

more of the following: subchondral cysts, subchondral sclerosis,

periarticular osteophytes, joint subluxation, bone on bone articulation

or joint space narrowing) of hip joint, or avascular necrosis

(osteonecrosis) with stage III collapse of the femoral head, or

rheumatoid arthritis (joint space narrowing); and

D. History of of unsuccessful conservative therapy (non-surgical

medical management) that is clearly addressed in the medical

record (see Note). If conservative therapy is not appropriate, the

medical record must clearly document why such approach is not

reasonable; or

II.

III.

IV.

Fracture of the femoral neck by imaging with pain interfering with ADLs; or

Malunion of acetabular, femoral head or proximal femur fracture with pain

interfering with ADLs; or

Nonunion by imaging or failure of previous hip fracture surgery with pain

interfering with ADLs; or

Page 2: Clinical Policy Bulletin: Total Hip Replacement - Aetna · Clinical Policy Bulletin: Total Hip Replacement Number: 0287 Policy Aetna considers an Food and Drug Administration-approved

Total Hip Replacement Page 2 of 15

http://qawww.aetna.com/cpb/medical/data/200_299/0287_draft.html 04/22/2015

V. Malignancy of the joint involving the bones or soft tissues of the pelvis or

proximal femur by imaging.

Note: Members with osteoarthritis, traumatic arthritis, rheumatoid arthritis,

or avascular necrosis should have at least 12 weeks of non-surgical

treatment documented in the medical record (at least 24 weeks for persons

with a relative contraindication* -- see below), including all of the following,

unless contraindicated:

A. Anti-inflammatory medications or analgesics; and

B. Flexibility and muscle strengthening exercises, and

C. Activity modification; and

D. Supervised physical therapy (ADLs diminished despite completing a

plan of care); and

E. Weight reduction as appropriate; and

F. Assistive device use (required for persons with relative

contraindications* to joint replacement, optional for others); and

G. Therapeutic injections into the hip (required for persons with relative

contraindications* to joint replacement, optional for others).

* Relative contraindicaitons to joint replacement include the

following: morbid obesity (BMI greater than 40), age less than 50

years). Persons with relative contraindications should exhaust all

non-surgical treatment options.

VI. Total joint replacement is considered not medically necessary in persons

with any of the following absolute contraindications:

A. Active infection of the joint or active systemic bacteremia that has

not been totally eradicated; or

B. Active skin infection (exception recurrent cutaneous staph infections)

or open wound within the planned surgical site of the hip; or

C. Allergy to components of the implant (e.g., cobalt, chromium or

alumina); or

D. Paraplegia or quadriplegia; or

E. Permanent or irreversible muscle weakness in the absence of pain

that prevents ambulation; or

F. Rapidly progressive neurological disease except in the clinical

situation of a concomitant displaced femoral neck fracture; or

G. Skeletal immaturity

VII.

VIII.

For persons with significant conditions or co-morbidities, the risk/benefit of

THA should be appropriately addressed in the medical record.

Aetna considers THAexperimental and investigational for all other

indications because of insufficient evidence of effectiveness.

Aetna considers a revision or replacement of a THA or hip resurfacing arthroplasty

medically necessary for the following indications when accompanied by pain and

functional disability (interference with ADLs):

Page 3: Clinical Policy Bulletin: Total Hip Replacement - Aetna · Clinical Policy Bulletin: Total Hip Replacement Number: 0287 Policy Aetna considers an Food and Drug Administration-approved

Total Hip Replacement Page 3 of 15

http://qawww.aetna.com/cpb/medical/data/200_299/0287_draft.html 04/22/2015

I.

II.

III.

IV.

V.

VI.

VII.

VIII.

IX.

Aseptic loosening of one or more prosthetic components confirmed by

imaging, or

Fracture or mechanical failure of 1 or more components of the

prosthesis confirmed by imaging, or

Confirmed periprosthetic infection confirmed by gram stain and culture, or

Displaced periprosthetic fracture confirmed by imaging, or

Progressive or substantial periprosthetic bone loss confirmed by imaging,

or

Bearing surface wear leading to symptomatic synovitis or local bone or soft

tissue reaction*, or

Recurrent (2 or more) dislocations confirmed by imaging not responsive to

a reasonable course of conservative management or irreducible dislocation

confirmed by imaging; or

Clinically significant leg length discrepancy; or

Upon individual case review, persistent hip pain of unknown etiology not

responsive to a period of non-surgical care for six (6) months.

And the member does not have any of the following contraindications to

total hip revision or replacement:

A. Loss of musculature (in particular hip abductor musculature),

neuromuscular compromise or vascular deficiency in the affected

limb, rendering the procedure unjustifiable; or

B. Osteoporosis or other osseous abnormalities which would make the

likelihood of a poor outcome more probable; or

C. Poor skin coverage; or

D. Severe instability due to anatomic causes that would make the

likelihood of a poor surgical outcome more probable.

Aetna considers a revision or replacement of a THA or hip resurfacing

experimental and investigational when criteria are not met.

Aetna considers minimal incision or minimally invasive THA a medically necessary

acceptable alternative to conventional THA.

Aetna considers measurement of synovial C-reactive protein experimental and

investigational as a marker for peri-prosthetic infection in THA because the

effectiveness of this approach has not been established.

* Aetna considers removal and revision surgery due to post total hip replacement

(THR) metallosis alone, without evidence of loosening or

malposition, experimental and investigational because there is insufficient clinical

evidence in the published peer-reviewed medical literature.

See also CPB 0661 - Joint Resurfacing.

Background

Page 4: Clinical Policy Bulletin: Total Hip Replacement - Aetna · Clinical Policy Bulletin: Total Hip Replacement Number: 0287 Policy Aetna considers an Food and Drug Administration-approved

Total Hip Replacement Page 4 of 15

http://qawww.aetna.com/cpb/medical/data/200_299/0287_draft.html 04/22/2015

Previously, most total hip prostheses utilize an acetabular cup either lined with

polyethylene or composed entirely of polyethylene articulating against a cobalt-

chromium-molybdenum (CoCr) or ceramic femoral head. Serious problems

affecting the outcome of total joint replacement with these types of prostheses

have been extensive and progressive peri-prosthetic osteolysis and aseptic

loosening, which may result in revision, even though the components are still well

fixed and functioning. Polyethylene particulate debris generated from metal-on-

polyethylene bearing surfaces and the resulting biologic response to this debris

are thought to be largely responsible.

In recent years, there has been renewed interest in metal-on-metal bearing

surfaces for total joint arthroplasty. This is especially true in younger and more

active patients who face the possibility of multiple revision procedures during their

lifetime. In the long-term, the second-generation all-metal prostheses have

demonstrated lower friction and wear rates than metal-on-polyethylene bearing

surfaces. Recent studies reported that the second-generation metal-on-metal hip

replacement prostheses exhibit a lower rate of acetabular revision and loosening

than did those with previous metal-on-metal designs and that they had no more

acetabular loosening or osteolysis than did those with metal-on-polyethylene

articulations for follow-up periods of 5 to 10 years.

Another alternative to standard polyethylene is alumina-on-alumina ceramic. When

comparing hard-on-hard bearings, the ceramic-on-ceramic coupling has several

theoretical advantages over metal-on-metal. Because of the ceramic's extremely

low coefficient of friction and its potential for superior wear resistance, these

couples promise both wear rates that are appreciably less than polyethylene

-on-metal and metal-on-metal couples.

Available literature indicates that alumina-on-alumina ceramic couplings are a

viable alternative to metal-on-polyethylene designs. The combination of new high

quality ceramic acetabular and femoral bearing heads with hip systems that have

achieved long-term stable fixation can result in a substantial increase in the

longevity of fixation for implants especially in the younger and more active

patients.

Available studies of metal-on-metal and ceramic-on-ceramic total hip implants

primarily involve cohorts of younger, more active patients. The chief advantage of

these hip implants over standard metal-on-polyethylene hip implants is their

greater longevity. There is no adequate evidence that metal-on-metal or ceramic-

on-ceramic total hip implants offer clinically significant benefits over standard

metal-on-polyethylene hip implants for older patients.

Bhandari et al (2005) reported a meta-analysis of 6 randomized controlled studies

suggested that bisphosphonates have a beneficial effect with regard to

maintaining more peri-prosthetic bone mineral density than that in controls.

However, the limitations of the available studies and the lack of analyses of

clinically relevant outcomes (e.g., functional outcomes, revision rates, and quality

of life) necessitate the planning and conduct of a sufficiently sized,

methodologically sound trial with clinically relevant end points. Until this has been

done, the current evidence regarding the beneficial effects of bisphosphonates on

Page 5: Clinical Policy Bulletin: Total Hip Replacement - Aetna · Clinical Policy Bulletin: Total Hip Replacement Number: 0287 Policy Aetna considers an Food and Drug Administration-approved

Total Hip Replacement Page 5 of 15

http://qawww.aetna.com/cpb/medical/data/200_299/0287_draft.html 04/22/2015

peri-prosthetic bone following total joint (e.g., knee and hip) arthroplasty should be

interpreted with caution.

A technology assessment of hip implants by the Institute for Clinical Effectiveness

and Health Policy (Augustovsky et al, 2006) found that the clinical trials comparing

ceramic against conventional prostheses found no significant differences in the

revision rate among the different types of prostheses. In case series of patients

with the ceramic prosthesis, reported revision rates at 10 years were less than 10

%, which is considered within acceptable limits and comparable to those reported

for conventional prostheses. Similar results have been reported for metal-on-

metal hip prostheses, where randomized controlled trials with follow-up up to 5

years found no differences between metal-on-metal and conventional

prostheses in effectiveness and complication rates (Augustovsky et al, 2006). The

assessment noted that, although there are some reports of an increase in cancer

in persons with metal-on-metal hip prostheses, there are other reports evaluating

metal-on-metal prostheses with follow-up up to 28 years that have found no

increase in the incidence of any cancer. The assessment stated that no study

comparing ceramic prosthesis with metal-on metal prosthesis was found. The

assessment concluded that, although interim results with both the ceramic and

metal-on-metal prostheses are promising, available studies have found no

significant differences in revision rates during follow-up periods of 10 to 15 years.

The assessment stated that, because the advantages of these materials may be

observed at longer terms, their potential benefits would be greatest for younger

patients (under 50 years of age) (Augustovsky et al, 2006).

In a meta-analysis, Smith and colleagues (2010) compared the clinical and

radiological outcomes and complication rates of hip resurfacing (HRS) and total

hip arthroplasty (THA). A systematic review was undertaken of all published

(Medline, CINAHL, AMED, EMBASE) and unpublished or gray literature research

databases up to January 2010. Clinical and radiological outcomes as well as

complications of HRS were compared to those of THA using risk ratio, mean

difference, and standardized mean difference statistics. Studies were critically

appraised using the CASP appraisal tool. A total of 46 studies were identified from

1,124 citations. These included 3,799 HRSs and 3,282 THAs. On meta-analysis,

functional outcomes for subjects following HRS were better than or the same as

for subjects with a THA, but there were statistically significantly greater incidences

of heterotopic ossification, aseptic loosening, and revision surgery with HRS

compared to THA. The evidence base showed a number of methodological

inadequacies such as the limited use of power calculations and poor or absent

blinding of both patients and assessors, possibly giving rise to assessor bias. The

authors concluded that on the basis of the current evidence base, HRS may have

better functional outcomes than THA, but the increased risks of heterotopic

ossification, aseptic loosening, and revision surgery following HRS indicate that

THA is superior in terms of implant survival.

Garbuz and associates (2010) conducted a prospective randomized clinical trial to

compare clinical outcomes of resurfacing versus large-head metal-on-metal THA.

These researchers randomized 107 patients deemed eligible for resurfacing

arthroplasty to have either resurfacing or standard THA. Patients were assessed

for quality-of-life outcomes using the PAT-5D index, WOMAC, SF-36, and UCLA

activity score. The minimum follow-up was 0.8 years (mean of 1.1 years; range of

Page 6: Clinical Policy Bulletin: Total Hip Replacement - Aetna · Clinical Policy Bulletin: Total Hip Replacement Number: 0287 Policy Aetna considers an Food and Drug Administration-approved

Total Hip Replacement Page 6 of 15

http://qawww.aetna.com/cpb/medical/data/200_299/0287_draft.html 04/22/2015

0.8 to 2.2 years). Of the 73 patients followed at least 1 year, both groups reported

improvement in quality of life on all outcome measures. There was no difference

in quality of life between the 2 arms in the study. Serum levels of cobalt and

chromium were measured in a subset of 30 patients. In both groups cobalt and

chromium was elevated compared to baseline. Patients receiving a large-head

metal-on-metal total hip had elevated ion levels compared to the resurfacing arm

of the study. At 1 year, the median serum cobalt increased 46-fold from baseline

in patients in the large-head total hip group, while the median serum chromium

increased 10-fold. At 1 year, serum cobalt was 10-fold higher and serum

chromium 2.6-fold higher than in the resurfacing arm. Due to these excessively

high metal ion levels, the authors recommended against further use of this

particular large-head THA.

Kim and colleagues (2013) stated that the timing of total hip replacement (THR) in

patients with active tuberculosis (TB) of the hip is controversial, because of the

potential risk of re-activation of infection. There is little information about the

outcome of THR in these patients. These investigators performed a systematic

review of published studies that evaluated the outcome of THR in patients with

active TB of the hip. A review of multiple databases referenced articles published

between 1950 and 2012 was carried out. A total of 6 articles were identified,

comprising 65 patients. Tuberculosis was confirmed histologically in all patients.

The mean follow-up was 53.2 months (range of 24 to 108). Anti-TB treatment

continued post-operatively for between 6 and 15 months, after debridement and

THR. One non-compliant patient had re-activation of infection. At the final follow-

up the mean Harris hip score was 91.7 (range of 56 to 98). The authors

concluded that THR in patients with active TB of the hip is a safe procedure,

providing symptomatic relief and functional improvement if undertaken in

association with extensive debridement and appropriate anti-TB treatment.

In a multi-center randomized, controlled trial with a non-inferiority design based on

a minimal clinically important difference of 2.0 %, Anderson et al (2013) compared

extended prophylaxis with aspirin and dalteparin for prevention of symptomatic

venous thrombo-embolism (VTE) after THA. Randomization was electronically

generated; patients were assigned to a treatment group through a Web-based

program. Patients, physicians, study coordinators, health care team members,

outcome adjudicators, and data analysts were blinded to interventions. The

setting of this study was 12 tertiary care orthopedic referral centers in Canada; and

a total of 778 patients who had elective unilateral THA between 2007 and 2010

were enrolled. After an initial 10 days of dalteparin prophylaxis after elective THA,

patients were randomly assigned to 28 days of dalteparin (n = 400) or aspirin (n =

386). Main outcome measures were symptomatic VTE confirmed by objective

testing (primary efficacy outcome) and bleeding. Five of 398 patients (1.3 %)

randomly assigned to dalteparin and 1 of 380 (0.3 %) randomly assigned to aspirin

had VTE (absolute difference, 1.0 percentage point [95 % confidence interval [CI]:

-0.5 to 2.5 percentage points]). Aspirin was non-inferior (p < 0.001) but not

superior (p = 0.22) to dalteparin. Clinically significant bleeding occurred in 5

patients (1.3 %) receiving dalteparin and 2 (0.5 %) receiving aspirin. The absolute

between-group difference in a composite of all VTE and clinically significant

bleeding events was 1.7 percentage points (CI: -0.3 to 3.8 percentage points; p =

0.091) in favor of aspirin. The authors concluded that extended prophylaxis for 28

days with aspirin was non-inferior to and as safe as dalteparin for the prevention of

Page 7: Clinical Policy Bulletin: Total Hip Replacement - Aetna · Clinical Policy Bulletin: Total Hip Replacement Number: 0287 Policy Aetna considers an Food and Drug Administration-approved

Total Hip Replacement Page 7 of 15

http://qawww.aetna.com/cpb/medical/data/200_299/0287_draft.html 04/22/2015

VTE after THA in patients who initially received dalteparin for 10 days. Given its

low cost and greater convenience, aspirin may be considered a reasonable

alternative for extended thrombo-prophylaxis following THA.

An UpToDate review on “Total hip arthroplasty” (Erens et al, 2014) states that:

“Contraindications -- Total hip arthroplasty (THA) should not be undertaken in a

number of clinical settings, including:

Active infection (local or systemic)

Preexisting significant medical problems (e.g., recent myocardial infarction,

unstable angina, heart failure, or severe anemia)

Skeletal immaturity

Paraplegia or quadriplegia

Permanent or irreversible muscle weakness in the absence of pain

Relative contraindications include a neuropathic (Charcot) joint, inability to

ambulate that is not related to the hip disorder per se, absence of hip abductor

muscle mass, progressive neurologic loss, and morbid obesity. However, the

effects of obesity on outcome remain uncertain. Most studies do show an

increased risk of infection, particularly in the highly obese. This must be weighed

against the fact that some morbidly obese patients can have significant

improvement postoperatively. A 2011 study from Canada noted that patients with

morbid obesity can experience substantial benefit, despite a very small but

statistically significant increase in the need for revision due to septic complications.

Other studies have emphasized the increased risk of both superficial and deep

infections and have described an increased risk of dislocation in such patients”.

Omar et al (2015) examined the role of synovial C-reactive protein (CRP) in the

diagnosis of chronic peri-prosthetic hip infection. These researchers prospectively

collected synovial fluid from 89 patients undergoing revision hip arthroplasty and

measured synovial CRP, serum CRP, erythrocyte sedimentation rate (ESR),

synovial white blood cell (WBC) count and synovial percentages of

polymorphonuclear neutrophils (PMN). Patients were classified as septic or

aseptic by means of clinical, microbiological, serum and synovial fluid findings.

The high viscosity of the synovial fluid precluded the analyses in 9 patients

permitting the results in 80 patients to be studied. There was a significant

difference in synovial CRP levels between the septic (n = 21) and the aseptic (n =

59) cohort. According to the receiver operating characteristic curve, a synovial

CRP threshold of 2.5 mg/L had a sensitivity of 95.5 % and specificity of 93.3 %.

The area under the curve was 0.96. Compared with serum CRP and ESR,

synovial CRP showed a high diagnostic value. The authors concluded that

according to these preliminary results, synovial CRP may be a useful parameter in

diagnosing chronic peri-prosthetic hip infection.

Furthermore, an UpToDate review on “Total hip arthroplasty” (Erens et al, 2014)

does not mention the use of synovial CRP as a post-operative management tool.

CPT Codes / HCPCS Codes / ICD-9 Codes

Total hip replacement (THA):

Page 8: Clinical Policy Bulletin: Total Hip Replacement - Aetna · Clinical Policy Bulletin: Total Hip Replacement Number: 0287 Policy Aetna considers an Food and Drug Administration-approved

Total Hip Replacement Page 8 of 15

http://qawww.aetna.com/cpb/medical/data/200_299/0287_draft.html 04/22/2015

CPT codes covered if selection criteria are met:

27130 Arthroplasty, acetabular and proximal femoral prosthetic

replacement (total hip arthroplasty), with or without autograft or

allograft [minimally invasive or conventional approach]

27132 Conversion of previous hip surgery to total hip arthroplasty,

with or without autograft or allograft [minimally invasive or

conventional approach]

HCPCS codes covered if selection criteria are met:

C1776 Joint device (implantable)

ICD-9 codes covered if selection criteria are met:

170.7 Malignant neoplasm of long bones of lower limb

198.5 Secondary malignant neoplasm of bone and bone marrow

714.0 Rheumatoid arthritis

715.15 Osteoarthrosis, localized, primary, pelvic region and thigh

715.25 Osteoarthrosis, localized, secondary, pelvic region and thigh

715.35 Osteoarthrosis, localized, not specified whether primary or

secondary, pelvic region and thigh

715.95 Osteoarthrosis, unspecified whether generalized or localized,

involving pelvic region and thigh

716.15 Traumatic arthropathy pelvic region and thigh

733.14 Pathologic fracture of neck of femur (hip)

733.81 -

733.82

Malunion and nonunion of fracture

733.40 Aseptic necrosis of bone, site unspecified

733.42 Aseptic necrosis of bone, head and neck of femur

808.0 Fracture of acetabulum, closed

808.1 Fracture of acetabulum, open

820.00 -

820.9

Fracture of neck of femur

905.3 Late effects of fracture of neck of femur

996.40 -

996.48

Mechanical complication of internal orthopedic device, implant,

and graft

V43.64 Joint replaced by other means, hip

Page 9: Clinical Policy Bulletin: Total Hip Replacement - Aetna · Clinical Policy Bulletin: Total Hip Replacement Number: 0287 Policy Aetna considers an Food and Drug Administration-approved

Total Hip Replacement Page 9 of 15

http://qawww.aetna.com/cpb/medical/data/200_299/0287_draft.html 04/22/2015

ICD-9 codes not covered if selection criteria are met:

001.0 - 139.8 Infectious and Parasitic Diseases [active infection of the joint,

active systemic bacteremia or active skin infection]

711.05 Pyogenic arthritis involving pelvic region and thigh

711.45 Arthropathy involving pelvic region and thigh associated with

other bacterial diseases

711.55 Arthropathy involving pelvic region and thigh associated with

other viral diseases

711.85 Arthropathy involving pelvic region and thigh associated with

other infectious and parasitic diseases

711.95 Unspecified infective arthritis involving pelvic region and thigh

890.0 - 890.2 Open wound of hip and thigh

985.6 Toxic effect of Chromium [not covered for metallosis alone

without evidence of loosening or malposition]

985.8 Toxic effect of other specified metals [not covered for

metallosis alone without evidence of loosening or malposition]

995.3 Allergy, unspecified, NEC

Other ICD-9 codes related to the CPB:

V13.51 -

V13.52

Personal history of pathologic and stress fracture

V15.51 Personal history of traumatic fracture, presenting hazards to

health

Revision, replacement of total hip arthroplasty, or revision hip resurfacing

arthroplasty:

No specific code

CPT codes covered if selection criteria are met:

27125 Hemiarthroplasty, hip, partial (eg, femoral stem prosthesis,

bipolar arthroplasty) [Revision of resurfacing arthroplasty]

27130 Arthroplasty, acetabular and proximal femoral prosthetic

replacement (total hip arthroplasty), with or without autograft or

allograft [revision of resurfacing arthroplasty]

27130 Arthroplasty, acetabular and proximal femoral prosthetic

replacement (total hip arthroplasty), with or without autograft or

allograft [revision of resurfacing arthroplasty]

Page 10: Clinical Policy Bulletin: Total Hip Replacement - Aetna · Clinical Policy Bulletin: Total Hip Replacement Number: 0287 Policy Aetna considers an Food and Drug Administration-approved

Total Hip Replacement Page 10 of 15

http://qawww.aetna.com/cpb/medical/data/200_299/0287_draft.html 04/22/2015

27134 -

27138

Revision of total hip arthroplasty; with or without autograft or

allograft

HCPCS codes covered if selection criteria are met:

C1776 Joint device (implantable)

S2118 Metal-on-metal total hip resurfacing, including acetabular and

femoral components

ICD-9 codes covered if selection criteria are met:

996.42 -

996.47

Mechanical complication of internal orthopedic device

996.66 Infection and inflammatory reaction due to internal joint

prosthesis

Other ICD-9 codes related to the CPB:

V43.64 Hip joint replacement status

The above policy is based on the following references:

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

Streicher RM. Metal-on-metal articulation in total hip arthroplasty: The case

for using metal-on-metal. J Arthroplasty. 1998;13(3):343-345.

Walker PS, Blunn GW. Metal-on-metal articulation in total hip arthroplasty:

The case for improving metal- or ceramic-on-polyethylene. J Arthroplasty.

1998;13(3):339-343.

Jazrawi LM, Kummer FJ, Di Cesare PE. Hard bearing surfaces in total hip

arthroplasty. Am J Orthop. 1998;27(4):283-292.

Faulkner A, Kennedy LG, Baxter K, et al. Effectiveness of hip prostheses in

primary total hip replacement: A critical review of evidence and an

economic model. Health Technol Assess. 1998;2(6):1-133.

Randle R, Gordiev K. Metal-on-metal articulation in total hip arthroplasty:

Preliminary results in 57 cases. Aust N Z J Surg. 1997;67(9):634-636.

Tountas AA. The historical development and clinical results on metal on

metal total hip systems. Clin Orthop. 1997;340:283-284.

Visuri T, Pukkala E, Paavolainen P, et al. Cancer risk after metal on metal

and polyethylene on metal total hip arthroplasty. Clin Orthop. 1996;329

(Suppl):S280-S289.

Black J. Metal on metal bearings. A practical alternative to metal on

polyethylene total joints? Clin Orthop. 1996;329(Suppl):S244-S255.

Hilton KR, Dorr LD, Wan Z, et al. Contemporary total hip replacement with

metal on metal articulation. Clin Orthop. 1996;329(Suppl):S99-S105.

Dorr LD, Hilton KR, Wan Z, et al. Modern metal on metal articulation for

total hip replacements. Clin Orthop. 1996;333:108-117.

Wagner H, Wagner M. Metal/metal articulating interfaces. Orthopedics.

1996;19(9):749-752.

Page 11: Clinical Policy Bulletin: Total Hip Replacement - Aetna · Clinical Policy Bulletin: Total Hip Replacement Number: 0287 Policy Aetna considers an Food and Drug Administration-approved

Total Hip Replacement Page 11 of 15

http://qawww.aetna.com/cpb/medical/data/200_299/0287_draft.html 04/22/2015

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

Amstutz HC, Campbell P, McKellop H, et al. Metal on metal total hip

replacement workshop consensus document. Clin Orthop. 1996;329

(Suppl):S297-S303.

Schmalzried TP, Peters PC, Maurer BT, et al. Long-duration metal-on-

metal total hip arthroplasties with low wear of the articulating surfaces. J

Arthroplasty. 1996;11(3):322-331.

Amstutz HC, Grigoris P. Metal on metal bearings in hip arthroplasty. Clin

Orthop. 1996;329(Suppl):S11-S34.

Muller ME. The benefits of metal-on-metal total hip replacements. Clin

Orthop. 1995;311:54-59.

Fraser J. Knee and hip joint replacements. Longer lasting prostheses. Aust

Fam Physicians. 1999;28(11):1109-1111, 1114-1115.

Sieber HP, Rieker CB, Kottig P. Analysis of 118 second-generation metal-

on-metal retrieved hip implants. J Bone Joint Surg Br. 1999;81(1):46-50.

Zahiri CA, Schmalzried TP, Ebramzadeh E, et al. Lessons learned from

loosening of the McKee-Farrar metal-on-metal total hip replacement. J

Arthroplasty. 1999;14(3):326-332.

Dorr LD, Wan Z, Longjohn DB, et al. Total hip arthroplasty with use of the

Metasul metal-on-metal articulation. Four to seven-year results. J Bone

Joint Surg Am. 2000;82(6):789-798.

Harkess JW. Arthroplasty of hip. In: Campbell's Operative Orthopaedics.

Vol I. 9th ed. ST Canale, ed. St. Louis, MO: Mosby; 1998; Ch. 7: 296-471.

Quintana JM, Azkarate J, Goenaga JI, et al. Evaluation of the

appropriateness of the hip joint replacement techniques. Intl J Tech Assess

Health Care. 2000;16(1):165-177.

Lombardi AV Jr, Mallory TH, Alexiades MM, et al. Short-term results of the

M2a-taper metal-on-metal articulation. J Arthroplasty. 2001;16(8 Suppl

1):122-128.

Garino JP. Modern ceramic-on-ceramic total hip systems in the United

States: Early results. Clin Orthop. 2000;(379):41-47.

Clarke IC, Good V, Williams P, et al. Ultra-low wear rates for rigid-on-rigid

bearings in total hip replacements. Proc Inst Mech Eng [H]. 2000;214

(4):331-347.

Bierbaum BE, Nairus J, Kuesis D, et al. Ceramic-on-ceramic bearings in

total hip arthroplasty. Clin Orthop. 2002;(405):158-163.

Canadian Coordinating Office for Health Technology Assessment

(CCOHTA). Relative benefits of various types of hip prostheses. Pre-

assessment No. 2. Ottawa, ON: CCOHTA; February 2002.

MacDonald SJ, McCalden RW, Chess DG, et al. Metal-on-metal versus

polyethylene in hip arthroplasty: A randomized clinical trial. Clin Orthop.

2003;(406):282-296.

U.S. Food and Drug Administration (FDA), Center for Devices and

Radiologic Health (CDRH. Ceramic TRANSCEND Hip Articulation System -

P010001. New Device Approval. CDRH Consumer Information. Rockville,

MD: FDA; March 25, 2003. Available at:

http://www.fda.gov/cdrh/mda/docs/p010001.html. Accessed July 15, 2003.

Augustovski F, Pichon Riviere A, Alcaraz A, et al. Usefulness of ceramic

prosthesis in total hip replacement. Report IRR No. 53. Buenos Aires,

Argentina: Institute for Clinical Effectiveness and Health Policy (IECS);

2005.

Page 12: Clinical Policy Bulletin: Total Hip Replacement - Aetna · Clinical Policy Bulletin: Total Hip Replacement Number: 0287 Policy Aetna considers an Food and Drug Administration-approved

Total Hip Replacement Page 12 of 15

http://qawww.aetna.com/cpb/medical/data/200_299/0287_draft.html 04/22/2015

30.

31.

32.

33.

34.

35.

36.

37.

38.

39.

40.

41.

42.

43.

44.

45.

Bhandari M, Bajammal S, Guyatt GH, et al. Effect of bisphosphonates on

periprosthetic bone mineral density after total joint arthroplasty. A meta-

analysis. J Bone Joint Surg Am. 2005;87(2):293-301.

Dumbleton JH, Manley MT. Metal-on-Metal total hip replacement: What

does the literature say? J Arthroplasty. 2005;20(2):174-188.

Yoo JJ, Kim YM, Yoon KS, et al. Alumina-on-alumina total hip arthroplasty.

A five-year minimum follow-up study. J Bone Joint Surg Am. 2005;87

(3):530-535.

Dorr LD, Wan Z, Shahrdar C, et al Clinical performance of a Durasul highly

cross-linked polyethylene acetabular liner for total hip arthroplasty at five

years. J Bone Joint Surg Am. 2005;87(8):1816-1821.

Parker MJ, Gurusamy K. Arthroplasties (with and without bone cement) for

proximal femoral fractures in adults. Cochrane Database Syst Rev. 2006;

(3):CD001706.

Parker MJ, Gurusamy K. Internal fixation versus arthroplasty for

intracapsular proximal femoral fractures in adults. Cochrane Database Syst

Rev. 2006;(4):CD001708.

Augustovski F, Pichon Riviere A, Alcaraz A, et al. Usefulness of ceramic or

metal on metal prostheses in total hip replacement [summary]. Report IRR

No. 84. Buenos Aires, Argentina: Institute for Clinical Effectiveness and

Health Policy (IECS); 2006.

Khan M, Kuiper JH, Richardson JB. Can cobalt levels estimate in-vivo wear

of metal-on-metal bearings used in hip arthroplasty? Proc Inst Mech Eng

[H]. 2007;221(8):929-942.

Morshed S, Bozic KJ, Ries MD, et al. Comparison of cemented and

uncemented fixation in total hip replacement: A meta-analysis. Acta Orthop.

2007;78(3):315-326.

Nowicki P, Chaudhary H. Total hip replacement in renal transplant patients.

J Bone Joint Surg Br. 2007;89(12):1561-1566.

Daras M, Macaulay W. Total hip arthroplasty in young patients with

osteoarthritis. Am J Orthop (Belle Mead NJ). 2009;38(3):125-129.

Garcia-Rey E, Cruz-Pardos A, Garcia-Cimbrelo E. Alumina-on-alumina total

hip arthroplasty in young patients: Diagnosis is more important than age.

Clin Orthop Relat Res. 2009;467(9):2281-2289.

Hooper GJ, Rothwell AG, Stringer M, Frampton C. Revision following

cemented and uncemented primary total hip replacement: A seven-year

analysis from the New Zealand Joint Registry. J Bone Joint Surg Br.

2009;91(4):451-458.

Pospischill M, Kranzl A, Attwenger B, Knahr K. Minimally invasive

compared with traditional transgluteal approach for total hip arthroplasty: A

comparative gait analysis. J Bone Joint Surg Am. 2010;92(2):328-337.

Smith TO, Nichols R, Donell ST, Hing CB. The clinical and radiological

outcomes of hip resurfacing versus total hip arthroplasty: A meta-analysis

and systematic review. Acta Orthop. 2010;81(6):684-695.

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.

2010;468(2):318-325.

Page 13: Clinical Policy Bulletin: Total Hip Replacement - Aetna · Clinical Policy Bulletin: Total Hip Replacement Number: 0287 Policy Aetna considers an Food and Drug Administration-approved

Total Hip Replacement Page 13 of 15

http://qawww.aetna.com/cpb/medical/data/200_299/0287_draft.html 04/22/2015

46.

47.

48.

49.

50.

51.

52.

53.

54.

55.

56.

57.

58.

59.

60.

61.

62.

Walsh J. Metal-on-metal hip resurfacing as an alternative to total hip

arthroplasty. Technology Assessment. San Francisco, CA: California

Technology Assessment Forum (CTAF); October 19, 2011.

Azegami S, Gurusamy KS, Parker MJ. Cemented versus uncemented

hemiarthroplasty for hip fractures: A systematic review of randomised

controlled trials. Hip Int. 2011;21(5):509-517.

Qu X, Huang X, Dai K. Metal-on-metal or metal-on-polyethylene for total hip

arthroplasty: A meta-analysis of prospective randomized studies. Arch

Orthop Trauma Surg. 2011;131(11):1573-1583.

U.S. Food and Drug Administration (FDA). Concerns about metal-on-metal

hip implant systems. Silver Spring, MD: FDA; updated March 29, 2012.

U.S. Food and Drug Administration (FDA). Information for orthopaedic

surgeons on meta-on-metal hip implant surgery. Silver Spring, MD; FDA;

updated March 29, 2012.

Matta JM, Ferguson TA. Total hip replacement after acetabular fracture.

Orthopedics. 2005;28(9):959-960.

Rogmark C, Johnell O. Primary arthroplasty is better than internal fixation of

displaced femoral neck fractures: A meta-analysis of 14 randomized studies

with 2,289 patients. Acta Ortho. 2006;77(3):359-367.

Blomfeldt R, Tornkvist H, Ponzer S, et al. Displaced femoral neck fracture:

Comparison of primary total hip replacement with secondary replacement

after failed internal fixation: A 2-year follow-up of 84 patients. Acta Orthop.

2006;77(4):638-643.

Harkess JW, Crockarell JR Jr. Arthroplasty of the hip. In: Canale ST, Beaty

JH (editors). Campbell's Operative Orthopaedics. 11th ed. Philadelphia, PA:

Mosby Elsevier; 2008:312-482.

Williams D, Taylor A, McLardy-Smith P. Revision arthroplasty: An update.

Skeletal Radiol. 2009;38(11):1031-1036.

Kim YH, Kwon OR, Kim JS. Is one-stage bilateral sequential total hip

replacement as safe as unilateral total hip replacement? J Bone Joint Surg

Br. 2009;91(3):316-320.

Wang J, Jiang B, Marshall RJ, Zhang P. Arthroplasty or internal fixation for

displaced femoral neck fractures: Which is the optimal alternative for elderly

patients? A meta-analysis. Int Orthop. 2009;33(5):1179-1187.

Zhang W, Nuki G, Moskowitz RW, et al. OARSI recommendations for the

management of hip and knee osteoarthritis: Part III: Changes in evidence

following systematic cumulative update of research published through

January 2009. Osteoarthritis Cartilage. 2010;18(4):476-499.

Hopley C, Stengel D, Ekkernkamp A, Wich M. Primary total hip arthroplasty

versus hemiarthroplasty for displaced intracapsular hip fractures in older

patients: Systematic review. BMJ. 2010;340:c2332.

Carroll EA, Huber FG, Goldman AT, et al. Treatment of acetabular fractures

in an older population. J Orthop Trauma. 2010;24(10):637-644.

Bozic KJ, Maselli J, Pekow PS, et al. The influence of procedure volumes

and standardization of care on quality and efficiency in total joint

replacement surgery. J Bone Joint Surg Am. 2010;92(16):2643-2652.

Leonardsson O, Sernbo I, Carlsson A, et al. Long-term follow-up of

replacement compared with internal fixation for displaced femoral neck

fractures: Results at ten years in a randomised study of 450 patients. J

Bone Joint Surg Br. 2010;92(3):406-412.

Page 14: Clinical Policy Bulletin: Total Hip Replacement - Aetna · Clinical Policy Bulletin: Total Hip Replacement Number: 0287 Policy Aetna considers an Food and Drug Administration-approved

Total Hip Replacement Page 14 of 15

http://qawww.aetna.com/cpb/medical/data/200_299/0287_draft.html 04/22/2015

63.

64.

65.

66.

67.

68.

69.

70.

71.

72.

73.

Wingerter SA, Mehrle RK. Hip disease and hip arthroplasty. Orthop Clin of

North Am. 2011;42(1):115-121.

Senthi S, Munro JT, Pitto RP. Infection in total hip replacement: Meta-

analysis. Int Orthop. 2011;35(2):253-260.

Dai Z, Li Y, Jiang D. Meta-analysis comparing arthroplasty with internal

fixation for displaced femoral neck fracture in the elderly. J Surg Res.

2011;165(1):68-74.

Kim SJ, Postigo R, Koo S, Kim JH. Total hip replacement for patients with

active tuberculosis of the hip: A systematic review and pooled analysis.

Bone Joint J. 2013;95-B(5):578-582.

Anderson DR, Dunbar MJ, Bohm ER, et al. Aspirin versus low-molecular-

weight heparin for extended venous thromboembolism prophylaxis after

total hip arthroplasty: A randomized trial. Ann Intern Med. 2013;158(11):800

-806.

Pennington M, Grieve R, Sekhon JS, et al. Cemented, cementless, and

hybrid prostheses for total hip replacement: Cost effectiveness analysis.

BMJ. 2013;346:f1026.

Shi-Peng Y, Yun J, Cheng-Fu L. Meta-analysis of the role of two common

prostheses in total hip replacement. Zhongguo Yi Xue Ke Xue Yuan Xue

Bao. 2013;35(6):672-676.

Abdulkarim A, Ellanti P, Motterlini N, et al. Cemented versus uncemented

fixation in total hip replacement: A systematic review and meta-analysis of

randomized controlled trials. Orthop Rev (Pavia). 2013;5(1):e8.

De Bellis UG, Legnani C, Calori GM. Acute total hip replacement for

acetabular fractures: A systematic review of the literature. Injury. 2014;45

(2):356-361.

Erens GA, Thornhill TS, Katz JN. Total hip arthroplasty. UpToDate [online

serial], Waltham, MA: UpToDate; reviewed December 2014.

Omar M, Ettinger M, Reichling M, et al. Synovial C-reactive protein as a

marker for chronic periprosthetic infection in total hip arthroplasty. Bone

Joint J. 2015;97-B(2):173-176.

Page 15: Clinical Policy Bulletin: Total Hip Replacement - Aetna · Clinical Policy Bulletin: Total Hip Replacement Number: 0287 Policy Aetna considers an Food and Drug Administration-approved

Total Hip Replacement Page 15 of 15

http://qawww.aetna.com/cpb/medical/data/200_299/0287_draft.html 04/22/2015

Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in

administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy

Bulletin contains only a partial, general description of plan or program benefits and does not constitute a

contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or

outcomes. Participating providers are independent contractors in private practice and are neither

employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice

and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.

CPT only copyright 2008 American Medical Association. All Rights Reserved.