Description
General Information

• It is an expectation that all patients receive care/services from a licensed clinician. All appropriate supporting documentation, including recent pertinent office visit notes, laboratory data, and results of any special testing must be provided. If applicable: All prior relevant imaging results and the reason that alternative imaging cannot be performed must be included in the documentation submitted.

• The guideline criteria in the following sections were developed utilizing evidence-based and peer-reviewed resources from medical publications and societal organization guidelines as well as from widely accepted standard of care, best practice recommendations.

Purpose

This guideline addresses elective, non-emergent hip arthroplasty (hip replacement) procedures, including total hip arthroplasty, resurfacing arthroplasty, and revision/conversion arthroplasty procedures.

Scope

Arthritis is the most common cause of chronic hip pain and disability. Degenerative, age-related osteoarthritis causes cartilage to wear away and eventually the bones within the joint rub against each other causing pain and stiffness.

Special Note

In order for surgeries to be considered medically necessary there must be clear medical records that demonstrate a clear surgical plan that matches the request for surgery.

General Requirements

• Elective hip arthroplasty may be considered if the following general criteria are met:
  • Moderate to severe hip pain with documented loss of function, which may include painful weight bearing, painful or inadequate range of motion to accomplish age-appropriate activities of daily living (ADLs) and/or employment, and mechanical catching, locking
  • Individual is medically stable and optimized for surgery, and any treatable comorbidities are adequately medically managed such as diabetes, nicotine addiction, or an excessively high body mass index (BMI). There should also be a shared decision between the patient and physician to proceed with a total joint replacement when comorbidities exist as it pertains to the increased risk of complications ⁽¹⁾
  • Individual does not have an active local or systemic infection
  • Individual does not have active, untreated drug dependency (including but not limited to narcotics, opioids, muscle relaxants) unless engaged in treatment program
  • Individual has good oral hygiene and does not have major dental work scheduled or anticipated (ideally, within one year of joint replacement), due to increased post-surgical infection risk
• Clinical notes should address:
  • Symptom onset, duration, and severity
  • Loss of function and/or limitations
  • Type and duration of non-operative management modalities

• • Discussion with patient regarding decision making and timing
• Non-operative management must include at least TWO or more of the following unless otherwise specified in clinical indications below ⁽²⁾ :
  • Rest or activity modifications/limitations
  • Weight reduction for individual with elevated BMI
  • Protected weight-bearing with cane, walker, or crutches
  • Physical therapy modalities
  • Physician-supervised exercise program (including home exercise program)
  • Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, or analgesics
  • Intra-articular injection(s)

Background

Grading Appendix ⁽⁶⁾

Tönnis Classification of Osteoarthritis by Radiographic Changes

INDICATIONS
Total Hip Arthroplasty (THA)
There is no medical necessity to perform THA in individuals with severe radiological disease and no symptoms, except in the case of malignancy.

THA may be considered medically necessary as indicated in either sections 1 or 2:

• Section One
  • Persistent pain and documented loss of function with radiographic evidence of disease from any of the following:
    • Rheumatoid arthritis or inflammatory arthritis ^(1,3)
    • Femoral neck fracture
    • Malignancy ⁽⁴⁾
    • Dysplasia ⁽³⁾
    • Congenital hip disorders ⁽³⁾
    • Avascular necrosis confirmed by imaging (radiographs, MRI, or other advanced imaging) ^(1,3,5)
    • Radiographs demonstrate bone-on-bone articulation ^(1,3,5)

• Section Two
  • There is persistent pain and documented loss of function for at least 12 weeks and includes all the following ^(1,3,5) :
    • Physical exam (PE) demonstrates findings of hip pathology as evidence by one or more of the following (PE is not required if bone-on-bone narrowing is present on X-ray):
      • Painful, limited range of motion or antalgic gait
      • Contractures
      • Crepitus
      • Leg length difference
  • Radiographic findings show evidence of advanced arthritic changes, described as Tönnis grade 2 or 3 [see Grading Appendix] or described as X-rays showing advanced changes (e.g., severe narrowing, bone-on-bone compartment collapse, subchondral sclerosis or cysts, osteophyte formation and/or bony deformity etc.) ⁽⁶⁾

X-rays described only as showing 'severe', 'advanced' or 'end-stage' arthritis require more definitive descriptions as stated above (weightbearing X-rays are not required)

NOTE: MRI should not be the primary radiographic test used to determine the presence or severity of arthritic changes in the joint.

• • Failure of at least 12 weeks of non-operative treatment, including at least two of the following ^(1–3,5) :
    • Rest or activity modifications/limitations
    • Weight reduction for individual with elevated BMI
    • Protected weight-bearing with cane, walker, or crutches
    • Physical therapy modalities
    • Physician supervised exercise program (including home exercise program)
    • Pharmacological treatment: oral/topical NSAIDs, acetaminophen, or analgesics
    • Intra-articular corticosteroid injection
  • No corticosteroid injection into the joint within 12 weeks of surgery ^(1,7–9)

Simultaneous Bilateral THA

• ALL requests for simultaneous bilateral total hip replacements should clearly indicate why simultaneous THA is preferable to staged procedures.
• Associated risks with simultaneous bilateral total hip replacements should be discussed with the patient and documented in their medical record ^(10,11)

Absolute Contraindications

• Any infection of joints, soft tissues or hematogenous infection, including any active infections. If local or active:
  • Document in the patient’s history, records should clearly demonstrate that the infection has been treated, and symptoms have resolved or that the individual has no clinical signs or symptoms of the previous infection at the time of the operation ^(3,5)
• Any corticosteroid injection into the joint within 12 weeks of surgery ^(1,7–9)

Relative Contraindications

• Prior infection at site (unless aspiration with cultures and serology [CBC with differential, ESR, CRP] demonstrates no infection). If prior infection at site, tissue biopsies should be sent intra-operatively to exclude latent/dormant infection ^(3,5)
• Known metal sensitivities (e.g. cobalt, chromium, nickel) ⁽¹²⁾
• BMI > 40kg/m²; without discussion of increased risk conferred by BMI ⁽⁵⁾

• Compromised soft tissue envelope
• Uncontrolled comorbidities ^(5,13)

Hip Resurfacing Arthroplasty

Hip resurfacing procedures will be reviewed on a case-by-case basis.

Hip resurfacing arthroplasty may be considered medically necessary when ALL of the following criteria are met ^(14,15) :

• Pain and documented loss of function are present for at least 12 weeks
• 12 weeks of non-operative treatment 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 Tönnis grade 2 or 3, or avascular necrosis involving less than 50% of the femoral head [see Grading Appendix]  ⁽⁶⁾
• Male patient is less than 60 years old or female patient is less than 55 years old ^(16,17)
• BMI < 40kg/m^{2 (12)}
• No corticosteroid injection into the joint within 12 weeks of surgery ^(1,7–9)

Absolute Contraindications  

• Any corticosteroid injection into the joint within 12 weeks of surgery ^(7–9)
• Osteoporosis or osteopenia Dual-energy X-ray Absorptiometry (DEXA) scan bone mineral density evaluation) ⁽¹⁸⁾
  • Osteoporosis or poor bone quality may increase the risk of fixation failure or femoral neck fracture after hip resurfacing ^(15,19)
  • Other co-morbidities (including medications that contribute to decreased bone mineral density that may contribute to active bone demineralization (glucocorticoid steroids, anticoagulants, aromatase inhibitors, thiazolidinediones, proton pump inhibitors, loop diuretics, antiretrovirals, anti-psychotics, anti-seizures, certain breast cancer drugs, certain prostate cancer drugs, progestin’s, aluminum containing antacids) ⁽¹⁸⁾
• Large bone defects or cystic degeneration at the junction of the femoral head and neck on radiographs,  Ultrasound (US), Magnetic Resonance Imaging (MRI), or Computed Tomography (CT) ^(12,14,15)
• Malignancy at the proximal femur
• Evidence of current, ongoing, or inadequately treated hip infection, or sepsis ⁽¹³⁾
• Female of child-bearing age (due to metal ions circulating in blood with potential risk to fetus) ⁽¹⁴⁾

• Chronic renal insufficiency (due to metal ions circulating and potential renal toxicity) ^(12,16)
• Known metal sensitivities (e.g. cobalt, chromium, nickel) ⁽¹²⁾

Revision/Conversion Arthroplasty

Hip revision/conversion arthroplasty for a prior hip arthroplasty, fracture Open Reduction and Internal Fixation (ORIF), or ANY prior hip surgery may be considered medically necessary when the following criteria in either section one or section two are met ^(20,21) :

• Section One
  • Previous removal of infected hip prosthesis*
  • No evidence of current, ongoing, or inadequately treated hip infection (ruled out by normal inflammatory markers (ESR and CRP) or significant improvement in these markers. If these inflammatory markers are elevated, further evaluation is required including an aspiration with synovial fluid WBC count, gram stain and cultures, or an intraoperative frozen biopsy
  • A clear statement by the treating surgeon that infection has been adequately treated
  • Patient is off antibiotics for 2 weeks

• Section Two
  • When all of the following criteria are met
    • Failed hip arthroplasty as defined by symptomatic or unstable joint upon physical examination with documented persistent, severe, or disabling pain with loss of function and/or instability. For symptomatic patients for conversion arthroplasty from prior ORIF or any prior hip surgery, radiographic evidence of advanced arthritis (Tönnis grade 2 or 3) is required
    • Physical exam and radiographic evidence support extensive disease or damage due to fracture, malignancy, osteolysis, other bone or soft-tissue reactive or destructive process, inappropriate positioning of components, recurrent instability, subluxation, dislocation, critical polyethylene wear, or other mechanical or hardware failure

NOTE: MRI is used less often in these circumstances unless it is a metal-on-metal prosthesis and looking for soft-tissue lesions; x-ray, CT, nuclear studies are used more frequently

• • • For implant loosening seen on routine X-rays or bone scan, documentation of no current, ongoing, or inadequately treated hip infection, ruled out by normal inflammatory markers (ESR and CRP). If these markers are elevated, a clear statement by the treating surgeon is required regarding the surgical plan to rule out infection
    • If the revision is for obvious hardware failure or recurrent dislocations, inflammatory markers are not required
    • No corticosteroid injection into the joint within 12 weeks of surgery ^(1,7–9)

*NOTE: Removal of infected hip prosthesis and subsequent insertion of antibiotic spacer is NOT considered to be a revision arthroplasty.

Rationale

SUMMARY OF EVIDENCE
2023 American College of Rheumatology and American Association of Hip and Knee Surgeons Clinical Practice Guideline for the Optimal Timing of Elective Hip or Knee Arthroplasty for Patients With Symptomatic Moderate-to-Severe Osteoarthritis or Advanced Symptomatic Osteonecrosis With Secondary Arthritis for Whom Nonoperative Therapy Is Ineffective ⁽¹⁾

• Study Design: This is a clinical practice guideline developed by the American College of Rheumatology and the American Association of Hip and Knee Surgeons. It uses a systematic literature review and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.
• Target Population: Patients with symptomatic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis who have not responded to nonoperative therapy and are considering elective hip or knee arthroplasty.
• Key Factors: The guideline provides evidence-based recommendations for the optimal timing of arthroplasty, including considerations for delaying surgery for nicotine reduction, glycemic control, and weight loss. It emphasizes shared decision-making between patients and physicians.

Indication Criteria for Total Hip Arthroplasty in Patients with Hip Osteoarthritis—Recommendations from a German Consensus Initiative⁽⁵⁾

• Study Design: This study is a consensus-based clinical practice guideline developed by a German multidisciplinary panel. It involved a systematic literature review and consensus meetings.
• Target Population: Patients with hip osteoarthritis considering total hip arthroplasty (THA).
• Key Factors: The guideline provides 31 recommendations for decision-making on THA, including minimum requirements such as confirmed diagnosis, assessment of illness burden, and ineffectiveness of non-surgical therapies. It also addresses modifiable risk factors and emphasizes shared decision-making.

Preoperative Corticosteroid Injections Demonstrate a Temporal and Dose-Dependent Relationship with the Rate of Postoperative Infection Following Total Hip Arthroplasty⁽⁷⁾

• Study Design: This study is a retrospective analysis using the PearlDiver database to investigate the relationship between corticosteroid injections (CSI) and the risk of periprosthetic joint infection (PJI) and surgical site infections (SSI) following total hip arthroplasty (THA).
• Target Population: Patients undergoing THA from 2011 to 2018 who had received intra-articular hip CSI prior to surgery.
• Key Factors: The study found a temporal and dose-dependent relationship between CSI and the risk of PJI and SSI. Injections within 4 months of surgery were associated with a higher incidence of PJI, and multiple injections increased the odds of infection.

ANALYSIS OF EVIDENCE
Shared Findings^(1,5,7):

• Emphasis on Shared Decision-Making: All three articles highlight the importance of shared decision-making between patients and physicians when considering THA. This ensures that the patient's individual circumstances, preferences, and risk factors are taken into account.
• Consideration of Modifiable Risk Factors: Both the Hannon and Lutzner guidelines emphasize the need to address modifiable risk factors such as nicotine use, glycemic control, and weight loss before proceeding with THA.

Differing Findings^(1,5,7):

• Timing and Dose-Dependency of CSI: The Forlenza study specifically investigates the relationship between preoperative CSI and the risk of postoperative infections, finding a clear temporal and dose-dependent relationship. This is not addressed in the Hannon and Lutzner guidelines.
• Guideline Recommendations: The Hannon guideline provides specific recommendations for the optimal timing of arthroplasty, including delaying surgery for certain risk factors, while the Lutzner guideline focuses on a broader set of criteria for decision-making on THA.

In summary, while all three articles emphasize the importance of shared decision-making and addressing modifiable risk factors, the Forlenza study provides specific evidence on the risks associated with preoperative CSI,⁽⁷⁾ and the Hannon and Lutzner guidelines offer comprehensive recommendations for the timing and criteria for THA.^(1,5)

References

1. Hannon CP, Goodman SM, Austin MS, et al. 2023 American College of Rheumatology and American Association of Hip and Knee Surgeons Clinical Practice Guideline for the Optimal Timing of Elective Hip or Knee Arthroplasty for Patients With Symptomatic Moderate‐to‐Severe Osteoarthritis or Advanced Symptomatic Osteonecrosis With Secondary Arthritis for Whom Nonoperative Therapy Is Ineffective. Arthritis Care Res (Hoboken). 2023;75(11):2227-2238. doi:10.1002/acr.25175
2. AAOS. Management of Osteoarthritis of the Hip Evidence-Based Clinical Practice Guideline. AAOS. Published online December 1, 2023. Accessed October 17, 2024. https://www.aaos.org/globalassets/quality-and-practice-resources/osteoarthritis-of-the-hip/oah-cpg.pdf
3. Varacallo M, Luo T, Johanson NA. Total Hip Arthroplasty Techniques. StatPearls. Published online August 4, 2023. https://www.ncbi.nlm.nih.gov/books/NBK507864/
4. Tepper SC, Lee L, Kasson LB, et al. Hip Arthroplasty Outcomes in Patients with Metastatic Bone Disease. Orthop Rev (Pavia). 2024;16. doi:10.52965/001c.94568
5. Lützner C, Deckert S, Günther KP, et al. Indication Criteria for Total Hip Arthroplasty in Patients with Hip Osteoarthritis—Recommendations from a German Consensus Initiative. Medicina (B Aires). 2022;58(5). doi:10.3390/medicina58050574
6. Kovalenko B, Bremjit P, Fernando N. Classifications in Brief: Tönnis Classification of Hip Osteoarthritis. Clin Orthop Relat Res. 2018;476(8):1680-1684. doi:10.1097/01.blo.0000534679.75870.5f
7. Forlenza EM, Burnett RA, Korrapati A, Yang JW, Forsythe B, Della Valle CJ. Preoperative Corticosteroid Injections Demonstrate a Temporal and Dose-Dependent Relationship with the Rate of Postoperative Infection Following Total Hip Arthroplasty. Journal of Arthroplasty. 2021;36(6):2033-2037.e1. doi:10.1016/j.arth.2021.01.076
8. Saracco M, Ciriello V, D’Angelo F, Zagra L, Solarino G, Logroscino G. Do prior intra-articular injections impact on the risk of periprosthetic joint infection in patients undergoing total hip arthroplasty? A meta-analysis of the current evidences with a focus on the timing of injection before surgery. EFORT Open Rev. 2023;8(6):459-467. doi:10.1530/EOR-23-0028
9. Werner BC, Cancienne JM, Browne JA. The Timing of Total Hip Arthroplasty After Intraarticular Hip Injection Affects Postoperative Infection Risk. Journal of Arthroplasty. 2016;31(4):820-823. doi:10.1016/j.arth.2015.08.032
10. Guo S jie, Shao H yi, Huang Y, Yang D jin, Zheng H long, Zhou Y xin. Retrospective Cohort Study Comparing Complications, Readmission, Transfusion, and Length of Stay of Patients Undergoing Simultaneous and Staged Bilateral Total Hip Arthroplasty. Orthop Surg. 2020;12(1):233-240. doi:10.1111/os.12617
11. Ramezani A, Ghaseminejad Raeini A, Sharafi A, Sheikhvatan M, Mortazavi SMJ, Shafiei SH. Simultaneous versus staged bilateral total hip arthroplasty: a systematic review and meta-analysis. J Orthop Surg Res. 2022;17(1). doi:10.1186/s13018-022-03281-4
12. U.S. Food and Drug Administration. Information for Orthopaedic Surgeons: General Recommendations for Orthopaedic Surgeons BEFORE Metal-on-Metal Hip Resurfacing Surgery. U.S. Food and Drug Administration. 2019. Accessed June 8, 2024. https://www.fda.gov/medical-devices/metal-metal-hip-implants/information-orthopaedic-surgeons
13. Patel I, Nham F, Zalikha AK, El-Othmani MM. Epidemiology of total hip arthroplasty: demographics, comorbidities and outcomes. Arthroplasty. 2023;5(1):2. doi:10.1186/s42836-022-00156-1
14. Al-Jabri T, Ridha M, McCulloch RA, et al. Hip Resurfacing Arthroplasty: Past, Present and Future. Orthop Rev (Pavia). 2023;15. doi:10.52965/001c.77745
15. Clough EJ, Clough TM. Metal on metal hip resurfacing arthroplasty: Where are we now? J Orthop. 2021;23:123-127. doi:10.1016/j.jor.2020.12.036
16. Sershon R, Balkissoon R, Valle CJD. Current indications for hip resurfacing arthroplasty in 2016. Curr Rev Musculoskelet Med. 2016;9(1):84-92. doi:10.1007/s12178-016-9324-0
17. Fan X, Zhou Y, Zhou T, Cobb JP, Yu T. The Choice of Hip Arthroplasty: HRA or THA? Revealed by Meta-Analysis. Orthop Surg. 2025;17(6):1577-1588. doi:10.1111/os.70019
18. Panday K, Gona A, Humphrey MB. Medication-induced osteoporosis: Screening and treatment strategies. Ther Adv Musculoskelet Dis. 2014;6(5):185-202. doi:10.1177/1759720X14546350
19. Adami G, Fassio A, Gatti D, et al. Osteoporosis in 10 years time: a glimpse into the future of osteoporosis. Ther Adv Musculoskelet Dis. 2022;14. doi:10.1177/1759720X221083541
20. Lee HD, Prashant K, Shon WY. Management of Periprosthetic Hip Joint Infection. Hip Pelvis. 2015;27(2):63-71. doi:10.5371/hp.2015.27.2.63
21. Tubb CC, Polkowksi GG, Krause B. Diagnosis and Prevention of Periprosthetic Joint Infections. Journal of the American Academy of Orthopaedic Surgeons. 2020;28(8):E340-E348. doi:10.5435/JAAOS-D-19-00405

Coding Section

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each Policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

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