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Hip Resurfacing

Metal-on-metal total hip resurfacing with a device system approved by the U.S. Food and Drug Administration (FDA) may be considered medically necessary as an alternative to total hip replacement when the patient:Is a candidate for total hip replacement; AND

Is likely to outlive a traditional prosthesis; AND

Does not have a contraindication for total hip resurfacing (see Policy Guidelines section).

Partial hip resurfacing with a FDA approved device may be considered medically necessary in patients with osteonecrosis of the femoral head who have 1 or more contraindications for metal-on-metal implants and meet the following criteria:

The patient is a candidate for total hip replacement; AND

Is likely to outlive a traditional prosthesis; AND

The patient has known or suspected metal sensitivity or concern about potential effects of metal ions; AND

There is no more than 50% involvement of the femoral head; AND

There is minimal change in acetabular cartilage or articular cartilage space identified on radiography.

All other types and applications of hip resurfacing are considered investigational.

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