CurrentBlue Cross Blue Shield - MassachusettsPolicy 046

046 Hip Resurfacing Prn

Defines medical necessity criteria, prior authorization requirements, and applicable codes for metal-on-metal total hip resurfacing and partial hip resurfacing as alternatives to total hip replacement for commercial and Medicare members of Blue Cross Blue Shield Massachusetts.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

Policy046 Hip Resurfacing Prn

Policy CodePolicy 046

Change TypeLiterature review; prior auth clarification

Effective Date

Next Review Date

Key ActionPrecertification/preauthorization is required for all products if the procedure is performed inpatient; document that medical necessity criteria and relevant radiographic findings are met.

SourceLink

POLICY UPDATE CHANGES

Policy updated with literature review through February 24, 2026; references added.

Outpatient prior authorization information clarified to N/A in 9/2019 (service primarily inpatient).

2Covered Indications (total and partial resurfacing)

1HCPCS code listed

>=1Key contraindication categories listed

Coverage Summary

Policy Number: 046; Subject: Hip resurfacing (total and partial). This coverage criteria defines medical necessity criteria, prior authorization requirements, and applicable codes for metal-on-metal total hip resurfacing and partial hip resurfacing as alternatives to total hip replacement for commercial and Medicare members of Blue Cross Blue Shield Massachusetts.

Background: Hip resurfacing is an alternative to total hip arthroplasty (THA) for patients with advanced hip arthritis, particularly younger, active patients who may outlive a traditional prosthesis; it can serve as a time-buying procedure to delay THA. The policy stance is mixed: metal-on-metal total hip resurfacing and partial hip resurfacing are listed as medically necessary when specific criteria are met, while all other types and applications are considered investigational.

Medical-Necessity Criteria

Metal-on-metal total hip resurfacing - Medically Necessary

Covered when ALL of the following are met:

ALL of the following

Is a candidate for total hip replacement
Is likely to outlive a traditional prosthesis
ALL of the following
- Contraindications (ANY of the following list may be considered contraindications)
  - Bone stock inadequate to support the device due to severe osteopenia or a family history of severe osteoporosis or severe osteopenia
  - Osteonecrosis or avascular necrosis with more than 50% involvement of the femoral head
  - Multiple cysts of the femoral head (>1 cm)
  - Skeletal immaturity
  - Vascular insufficiency, muscular atrophy, or neuromuscular disease severe enough to compromise implant stability or postoperative recovery
  - Known moderate-to-severe renal insufficiency
  - Severely overweight
  - Known or suspected metal sensitivity
  - Immunosuppressed or receiving high doses of corticosteroids
  - Individuals with childbearing potential of childbearing age due to unknown effects on the fetus of metal ion release

Partial hip resurfacing - Medically Necessary

Partial hip resurfacing with an FDA approved device may be considered MEDICALLY NECESSARY when ALL of the following are met:

ALL of the following

The individual is a candidate for total hip replacement
Is likely to outlive a traditional prosthesis
The individual has known or suspected metal sensitivity or concern about potential effects of metal ions
There is no more than 50% involvement of the femoral head<= 50% involvement
There is minimal change in acetabular cartilage or articular cartilage space identified on radiography

Not covered / Investigational

All other types and applications of hip resurfacing:

All other types and applications of hip resurfacing are considered INVESTIGATIONAL

Coding

Covered HCPCS code for hip resurfacing (informational)HCPCSCovered

S2118

Metal-on-metal total hip resurfacing, including acetabular and femoral components

Allowed ICD-10 diagnosis codes (when medical necessity criteria are met)ICD-10Covered

M16.0	Bilateral primary osteoarthritis of hip
M16.10	Unilateral primary osteoarthritis, unspecified hip
M16.11	Unilateral primary osteoarthritis, right hip
M16.12	Unilateral primary osteoarthritis, left hip
M16.2	Bilateral osteoarthritis resulting from hip dysplasia
M16.30	Unilateral osteoarthritis resulting from hip dysplasia, unspecified hip
M16.31	Unilateral osteoarthritis resulting from hip dysplasia, right hip
M16.32	Unilateral osteoarthritis resulting from hip dysplasia, left hip
M16.4	Bilateral post-traumatic osteoarthritis of hip
M16.50	Unilateral post-traumatic osteoarthritis, unspecified hip

1–10 of 18

1/2

Provider Actions

Prior Authorization

Precertification required for inpatient procedures

Precertification/preauthorization is required for all products if the procedure is performed inpatient. Outpatient prior authorization is not required per policy clarifications (service is primarily performed inpatient).

Outpatient prior authorization: Not required / N/A per policy (service primarily inpatient).

Documentation Required

Document medical necessity and contraindications

Document that medical necessity criteria are met: the patient is a candidate for total hip replacement, is likely to outlive a traditional prosthesis, and does not have contraindications for total hip resurfacing. Also document relevant radiographic findings, including the status of acetabular cartilage/articular cartilage space and the degree of femoral head involvement.

Acetabular cartilage or articular cartilage space (minimal change supports partial resurfacing).
Degree of femoral head involvement (≤ 50% for partial resurfacing; >50% may be a contraindication).

Billing Rule

Use current procedure and diagnosis codes

Providers should report services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable. The codes listed are informational and inclusion does not guarantee coverage unless medical necessity criteria are met.

HCPCS: S2118
ICD-10: M16.0, M16.10, M16.11, M16.12, M16.2, M16.30, M16.31, M16.32, M16.4, M16.50, M16.51, M16.52, M16.6, M16.7, M16.9, M87.051, M87.052, M87.059

Background and Evidence

Purpose: Hip resurfacing (placement of a shell covering the femoral head with an acetabular cup) is intended as an alternative to THA for patients with painful hip joints who are likely to outlive a conventional prosthesis. Metal-on-metal devices evolved to address polyethylene wear-related failures and may offer potential benefits such as preservation of femoral bone and reduced dislocation risk due to a larger resurfaced head.

Risks: Metal-on-metal components carry concerns about sensitivity and adverse local and systemic effects, including metallosis and pseudotumor formation, with an evolving literature on implant-related adverse events and failures. Partial (hemi) resurfacing is described as an option for avascular necrosis/osteonecrosis of the femoral head, particularly when metal-on-metal implants are contraindicated.

Total hip resurfacing: Evidence from randomized trials, large observational studies, registries, and systematic reviews shows that for selected patients who would outlive a traditional prosthesis and have no contraindications, metal-on-metal total hip resurfacing has similar short-to-medium term efficacy to THA and is a reasonable alternative when performed by experienced surgeons.

Concerns and evolving evidence: The literature on adverse events (for example, metallosis, pseudotumors, implant failure) is evolving with longer follow-up; due to uncertain risks with metal-on-metal implants the risk-benefit ratio should be considered individually. Emerging evidence suggests a possible increased risk of failure in women, potentially related to smaller implant size.

Partial hip resurfacing: Comparative evidence indicates outcomes are generally better with total resurfacing than partial resurfacing, but partial hip resurfacing may be appropriate for younger patients with osteonecrosis who have contraindications to metal-on-metal prostheses; the evidence is sufficient to conclude improvement in net health outcome when criteria are met.

Total hip resurfacing: Placement of a shell that covers the femoral head together with implantation of an acetabular cup; typically metal-on-metal devices.

Partial hip resurfacing: Resurfacing limited to part of the femoral head, considered for avascular necrosis with collapse when metal-on-metal implants are contraindicated.

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