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.

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.

GENERAL REQUIREMENTS

• Elective hip arthroplasty may be considered if the following general criteria are met:
  • 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 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)

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 ^(1,3,4):

• Section One
  • There is persistent pain and documented loss of function with radiographic evidence of advanced disease from any of the following
    • Rheumatoid arthritis
    • Femoral neck fracture
    • Malignancy
    • Dysplasia
    • Avascular necrosis confirmed by imaging (radiographs, MRI, or other advanced imaging)
    • Radiographs demonstrate bone-on-bone articulation
• Section Two
  • There is persistent pain and documented loss of function for at least 12 weeks and includes all the following:
    • Physical exam 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
      • Contracture
      • 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.)
  • 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
    • Rest or inactivity 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^(1,5,6,7)

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 also be discussed with the individual and documented in the medical record ^(8,9)

Absolute Contraindications

• Active infection (local or remote). If a local or remote infection is documented in the patient’s history, records should clearly demonstrate that the previous infection had 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⁾
• Any corticosteroid injection into the joint within 12 weeks of surgery ^(1,5,6,7)

Relative Contraindications ^(3,4)

• 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
• Documented allergy to any proposed component
• BMI > 40kg/m2; without discussion of increased risk conferred by BMI
• Compromised soft tissue envelope
• Uncontrolled comorbidities ⁽¹⁰⁾

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 ^(11,12):

• 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]
• Male patient is less than 65 years old or female patient is less than 55 years old ⁽¹³⁾
• BMI < 40 ⁽¹⁴⁾
• No corticosteroid injection into the joint within 12 weeks of surgery ^(1,5,6,7)

Absolute Contraindications  ^{(11,12,13,14)}

• Any corticosteroid injection into the joint within 12 weeks of surgery ^(1,5,6,7)
• Osteoporosis or osteopenia (DEXA scan bone mineral density evaluation)  
  • Osteoporosis or poor bone quality may increase the risk of fixation failure or femoral neck fracture after hip resurfacing
  • 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) ⁽¹⁵⁾
• Cystic degeneration at the junction of the femoral head and neck on radiographs or MRI or CT
• Malignancy at the proximal femur
• Evidence of current, ongoing, or inadequately treated hip infection, or sepsis
• Female of child-bearing age (due to metal ions circulating in blood with potential risk to fetus)  
• Chronic renal insufficiency (due to metal ions circulating and potential renal toxicity)  
• Metal allergy

Revision/Conversion Arthroplasty
Hip revision/conversion arthroplasty for a prior hip arthroplasty, fracture ORIF, or ANY prior hip surgery may be considered medically necessary when the following criteria in either section one or section two are met ^(16,17):

• 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
• 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 ^(1,5,6,7)

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

Grading Appendix⁽¹⁹⁾

Tõnnis Classification of Osteoarthritis by Radiographic Changes

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.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

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