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:
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:
* 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.
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):
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
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 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 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 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:
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-10 Codes|
|Information in the [brackets] below has been added for clarification purposes.  Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015 :|
|Total hip replacement (THA):|
|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]|
|CPT codes not covered for indications listed in the CPB:|
|86140 - 86141||C-reactive protein [as a marker for peri-prosthetic infection]|
|HCPCS codes covered if selection criteria are met:|
|C1776||Joint device (implantable)|
|ICD-10 codes covered if selection criteria are met:|
|C40.20 - C40.22||Malignant neoplasm of long bones of lower limb [proximal femur]|
|C79.51||Secondary malignant neoplasm of bone [proximal femur]|
|M05.00 - M14.89||Rheumatoid arthritis|
|M12.551 - M12.559||Traumatic arthropathy, hip|
|M16.0 - M16.9||Osteoarthritis of hip|
|M16.2 - M16.7||Osteoarthritis, secondary, hip|
|M16.9||Osteoarthritis of hip unspecified|
|M80.051+ - M80.059+
M80.851+ - M80.859+
M84.451+ - M84.453+, M84.459+
M84.551+ - M84.559+, M84.651+ - M84.659+
|Pathologic fracture of neck of femur (hip)|
|M87.00, M87.10, M87.20, M87.30
M87.80, M87.9, M90.50
|Osteonecrosis of bone, site unspecified|
|M87.051 - M87.059, M87.151 - M87.159
M87.251 - M87.255, M87.351 - M87.353
M87.851 - M87.859, M90.551 - M90.559
|Osteonecrosis of femur|
|S32.411+ - S32.9xx+||Fracture of acetabulum, closed and open|
|S72.001+ - S72.26x+||Fracture of head and neck of femur|
|T84.010 - T84.011, T84.020 - T84.021
T84.030 - T84.031, T84.040 - T84.041
T84.050 - T84.051, T84.060 - T84.061
T84.090 - T84.091
|Mechanical complication of internal orthopedic device, implant, and graft|
|Z96.641 - Z96.649||Presence of artificial hip joint|
|ICD-10 codes contraindicated for this CPB :|
|A00.0 - B99||Infectious and parasitic diseases [active infection of the joint, active systemic bacteremia or active skin infection]|
|G82.20 - G82.54||Paraplegia (paraparesis) and quadriplegia (quadriparesis)|
|M00.051 - M00.059, M00.151 - M00.159, M00.251 - M00.259, M00.851 - M00.859, M00.9||Pyogenic arthritis involving pelvic region and thigh|
|M01.X51 - M01.X59||Direct infection of hip in infection and parasitic diseases classified elsewhere|
|M62.81||Muscle weakness (generalized) [permanent or irreversible muscle weakness preventing ambulation in the absence of pain|
|R62.50, R62.59||Lack of expected normal physiological development in childhood [skeletal immaturity]|
|S71.001+ - S71.159||Open wound of hip and thigh|
|T56.2x1+ - T56.2x4+||Toxic effect of chromium and its compounds [not covered for metallosis alone without evidence of loosening or malposition]|
|T56.811+ - T56.894||Toxic effect of other metals [not covered for metallosis alone without evidence of loosening or malposition]|
|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]|
|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-10 codes covered if selection criteria are met:|
|T84.010+ - T84.099||Mechanical complication of internal joint prosthesis|
|T84.50x+ - T84.59x+||Infection and inflammatory reaction due to intenal joint prosthesis|