CurrentBluecross IdahoPolicy MP 7.01.80

Hip Resurfacing

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This policy governs medical necessity and coverage for total and partial hip resurfacing procedures using FDA-approved devices as alternatives to total hip replacement, and it applies to members covered under Blue Cross of Idaho benefit plans.

Policy Summary

PayerBluecross Idaho

PolicyHip Resurfacing

Policy CodePolicy MP 7.01.80

Change TypeNo material change

Effective DateApr 30, 2026

Last ReviewApr 30, 2026

Next Review DateApr 25, 2025

Key ActionObtain and document prior authorization showing the patient meets candidate selection criteria and device details when requesting resurfacing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2types addressed

50%partial femoral involvement limit

96.0%15-yr male survivorship

4.7%overall Birmingham revision rate

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CurrentBluecross IdahoPolicy MP 7.01.80

Hip Resurfacing

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Policy Summary

PayerBluecross Idaho

PolicyHip Resurfacing

Policy CodePolicy MP 7.01.80

Change TypeNo material change

Effective DateApr 30, 2026

Last ReviewApr 30, 2026

Next Review DateApr 25, 2025

Key ActionObtain and document prior authorization showing the patient meets candidate selection criteria and device details when requesting resurfacing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2types addressed

50%partial femoral involvement limit

96.0%15-yr male survivorship

4.7%overall Birmingham revision rate

Coverage Criteria for Hip Resurfacing

Total hip resurfacing — medical necessity

Covered when ALL of the following are met for metal-on-metal total hip resurfacing:

Total hip resurfacing criteria: Is a candidate for total hip replacement

Total hip resurfacing criteria: Is likely to outlive a traditional prosthesis

Total hip resurfacing criteria: Does not have a contraindication for total hip resurfacing (see Policy Guidelines)

Partial hip resurfacing — medical necessity

Partial hip resurfacing is covered when ALL of the following are met:

Partial hip resurfacing criteria: Is a candidate for total hip replacement

Partial hip resurfacing criteria: Is likely to outlive a traditional prosthesis

Partial hip resurfacing criteria: The individual has known or suspected metal sensitivity or concern about potential effects of metal ions

Partial resurfacing applies when metal-on-metal is contraindicated or not desired.

Partial hip resurfacing criteria: There is no more than 50% involvement of the femoral head<=50%

Partial hip resurfacing criteria: There is minimal change in acetabular cartilage or articular cartilage space on radiography

Investigational indications

Investigational: All other types and applications of hip resurfacing

These are considered investigational.

Patient selection and risk factors

Consider total hip resurfacing when ALL of the following apply (selection framework reflected in the evidence):

Primary selection considerations: Patient has hip osteoarthritis and anatomic/bone morphology suitable for resurfacing; candidate is typically a younger male (commonly <65 years) with relatively normal bony morphology.

Supported by Nunley review and cohort survivorship data.

Relative contraindications / risk factors: Female patients (especially postmenopausal or with decreased bone mineral density), BMI >35 kg/m2, poor bone density, femoral head cysts, head-neck junction abnormalities, small femoral component size (≤46 mm) are associated with higher failure/revision rates and should be cautiously considered.

Observed in registry and cohort data; small component size associated with higher revision.

Evidence synthesis: outcomes

Evidence comparing resurfacing to THA (synthesized findings):

Functional and quality-of-life outcomes: Multiple randomized trials and systematic reviews report similar functional outcome scores (e.g., WOMAC, UCLA, Harris/Oxford) between resurfacing and THA in short- to mid-term follow-up.

Fan 2025, Za 2024, Shanaa 2025.

Complications and revision rates: Findings are mixed: some meta-analyses report similar revision rates while others report increased revision risk with resurfacing in certain analyses; registry and cohort series report long-term survivorship that varies by device, sex, and component size.

Jiang 2011 showed increased revision risk in pooled analysis; Davey 2023 and Zuke 2025 report favorable long-term survivorship in selected cohorts.

Metal ions and device-specific harms: Metal ion levels and adverse reactions to metal debris have been reported and vary by implant type; monitoring thresholds (e.g., 7 ppb) and device-specific harms such as pseudotumor or metallosis are documented causes of revision.

Supported by systematic reviews and cohort studies reporting metal ion data and adverse events.

Partial Hip Resurfacing — Candidate Selection

Covered when ALL of the following are met

Partial hip resurfacing candidacy: Patient has avascular necrosis of the femoral head with no greater than 50% involvement; patient is a younger, physically active individual for whom bone preservation is a priority and who may outlive a conventional THA≤50% femoral head involvement

Derived from population and purpose statements

Total Hip Resurfacing — Evidence-informed coverage considerations

Coverage considerations informed by evidence

Favorable evidence: Multiple cohort studies and pooled analyses report good short- to medium-term survivorship (e.g., pooled 10-year survival ~95.5%; selected male cohorts show 15-year survivorship ~96%)

May support coverage in selected patients (younger males with larger femoral components)

Risk factors for poorer outcomes: Female sex, smaller femoral component size, and certain implant designs are associated with higher failure and metallosis/pseudotumor risk; some registry data show higher long-term revision hazard for resurfacing versus THA

These factors may lead to denial or require stricter selection/documentation

Appropriateness: Partial vs Total Hip Resurfacing

Coverage stance and clinical preference statements from the evidence review:

Preference for total resurfacing when no contraindication: Total hip resurfacing (femoral and acetabular implant) is preferred over femoral-only partial hip resurfacing for younger patients who do not have contraindications for the metal-on-metal prosthesis.

From Section Summary: increased poor outcomes with partial resurfacing compared with total resurfacing; partial appropriate if contraindication to metal-on-metal exists.

Appropriate use of partial resurfacing: Partial hip resurfacing would be appropriate in patients with osteonecrosis who have contraindications for a metal-on-metal prosthesis.

Clinical exception noted in Summary of Evidence.

The FDA lists multiple contraindications to total hip resurfacing that should be confirmed before approving coverage. Key FDA-listed contraindications include inadequate bone stock from severe osteopenia/osteoporosis, osteonecrosis with >50% femoral head involvement, or multiple femoral-head cysts (>1 cm); skeletal immaturity; severe vascular or neuromuscular compromise; moderate-to-severe renal insufficiency; severe overweight; known or suspected metal sensitivity; immunosuppression or high-dose corticosteroid therapy; and individuals of childbearing potential because of possible fetal effects of metal ion release.

Obesity and poor bone quality are recognized candidate cautions for resurfacing. The policy notes BMI >35 kg/m2 as a relative contraindication to total hip resurfacing and cites poor bone density, femoral head cysts, and head–neck junction abnormalities as additional risk factors that may exclude candidacy or prompt additional review.

Several patient- and implant-related factors are linked to higher failure or revision rates and should inform selection and prior-authorization review. Evidence identifies female sex (particularly postmenopausal women), small femoral component sizes (smaller head diameter), and poor bone quality as associated with increased risk of revision and adverse outcomes after resurfacing.

Contraindications specific to metal-on-metal resurfacing include known or suspected metal sensitivity, moderate or worse renal dysfunction, and women of childbearing potential (due to concern about metal ion transfer to a fetus). The Hip Society guidance also lists osteoporosis, large cysts, and avascular necrosis involving >50% of the femoral head as contraindications to metal-on-metal resurfacing.

No additional miscellaneous exclusions or criteria are explicitly listed in this excerpt beyond the FDA and Hip Society contraindications detailed elsewhere in the policy.

Any hip resurfacing types and applications not meeting the policy’s specified medical necessity criteria (i.e., not FDA-approved total resurfacing per the criteria or partial resurfacing that meets the listed indications and thresholds) are considered investigational and not medically necessary.

The literature and registry data indicate particular caution for older female patients. The policy highlights that women—especially postmenopausal women or those with decreased bone mineral density—have higher observed revision rates and should be evaluated cautiously; this supports conservative selection for resurfacing in older female patients.

Registry analyses and cohort studies raise concerns about use of specific devices in populations with higher observed revision rates. For example, use of the Birmingham Hip Resurfacing system in some registry cohorts showed higher long-term all-cause revision hazard compared with THA, indicating that device-specific registry performance should be considered when approving resurfacing in higher-risk populations.

Partial (femoral-only) hip resurfacing has been associated with increased poor outcomes compared with total hip resurfacing in the literature. Comparative studies and section summaries report less consistent pain relief and higher rates of problems believed related to continued abrasion or misfit against native acetabular cartilage, supporting preference for total resurfacing when metal-on-metal is appropriate.

Within this document excerpt there are no explicit statements labeled verbatim as 'not medically necessary' beyond the general policy stance that indications not meeting the specified medical necessity criteria are investigational or not medically necessary.

Coding and Key Numeric Thresholds

Codes table referencedmixed

No codes listed

Regulatory/Product Codemixed

NXT	FDA product code for partial hip resurfacing

Procedure/CPT CodesCPT

27130	Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty)
Unlisted procedure, pelvis or hip joint	Provider may report an unlisted code when no specific CPT exists

Procedure/HCPCS CodesHCPCS

S2118

Unlisted procedure, pelvis or hip joint — Metal-on-metal total hip resurfacing, including acetabular and femoral components (HCPCS)

Diagnosis ICD-10-CM CodesICD-10

M16.10-M16.9	Osteoarthritis of hip code range (ICD-10-CM)
M87.051-M87.059	Idiopathic aseptic necrosis of femur (ICD-10-CM)

ICD-10-PCS (inpatient)ICD-10

0SUA0BZ, 0SUE0BZ, 0SUR0BZ, 0SUS0BZ

ICD-10-PCS codes for surgical procedures on hip (inpatient only); specific codes for acetabular or femoral surface, right or left

inv-24: Maximum femoral head involvement for partial resurfacing

Maximum femoral head involvement for partial resurfacingNo more than 50% involvement of the femoral head (≤50%)

inv-25: metal ion toxicity threshold — 7 parts per billion (ppb)

Metal ion toxicity monitoring threshold7 parts per billion (ppb) — reported threshold for cobalt/chromium levels in trials

inv-26: obesity threshold (BMI) — > 35 kg/m2

Obesity as a relative contraindicationBody mass index (BMI) greater than 35 kg/m2 is considered a relative contraindication

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior authorization and medical necessity

Prior authorization is implied: verify member eligibility, reference the member-specific benefit plan, and confirm the device is FDA-approved when requesting coverage for total or partial hip resurfacing. Medical necessity criteria in this policy must be met for authorization.

Identify member eligibility and the member-specific benefit plan prior to submission.
Confirm the device system is FDA-approved when requesting metal-on-metal total hip resurfacing.

Prior Authorization

Document candidate selection for prior authorization

For prior authorization, document that the patient is an appropriate candidate for resurfacing — include age/sex considerations, bone morphology/quality, BMI, and surgeon rationale that the patient is a candidate for total hip replacement and likely to outlive a traditional prosthesis.

Document patient age and sex and explain candidacy (policy notes younger males commonly <65 years as optimal candidates).

Background and Context

Hip resurfacing is presented as an alternative to total hip arthroplasty (THA) for patients with advanced hip arthritis, particularly younger, active individuals who may outlive a conventional prosthesis. Total hip resurfacing involves placing a shell over the femoral head with an acetabular cup and may preserve femoral bone stock, potentially easing future revision to THA, but carries specific concerns about metal ion exposure and device-specific risks.

Definitions

inv-49: Total hip resurfacing — placement of a shell that covers the femoral head together with implantation of an acetabular cup

Total hip resurfacing definitionPlacement of a shell that covers the femoral head together with implantation of an acetabular cup

inv-50: Partial hip resurfacing — femoral (partial) resurfacing, devices via FDA 510(k), considered for avascular necrosis

Partial hip resurfacing descriptionFemoral (partial) resurfacing — femoral-component-only procedure; devices may be cleared via FDA 510(k) and considered for avascular necrosis

inv-51: Definition — placement of a shell that covers the femoral head together with implantation of an acetabular cup (total hip resurfacing)

Total hip resurfacing (alternate phrasing)Placement of a shell that covers the femoral head together with implantation of an acetabular cup (total hip resurfacing)

Policy Summary

PayerBluecross Idaho

PolicyHip Resurfacing

Policy CodePolicy MP 7.01.80

Change TypeNo material change

Effective DateApr 30, 2026

Last ReviewApr 30, 2026

Next Review DateApr 25, 2025

Key ActionObtain and document prior authorization showing the patient meets candidate selection criteria and device details when requesting resurfacing.

SourceLink

On This Page

inv-27: Femoral head size — larger than 50 mm (ideal candidate per Hip Society)

Femoral head size for ideal candidateFemoral head larger than 50 mm is noted as an ideal candidate characteristic (Hip Society)

Include assessment of bone morphology/quality and BMI considerations (e.g., obesity/BMI >35 kg/m2 is a relative contraindication).

Provide surgeon rationale and implant details supporting choice of resurfacing over THA.

Prior Authorization

Prior authorization recommended for resurfacing requests

Consider submitting a prior authorization request for partial or total hip resurfacing with clinical documentation of diagnosis (for example, extent of avascular necrosis), patient age/activity expectations, and the rationale comparing resurfacing versus conventional THA.

Include diagnostic documentation such as radiographic evidence and extent of avascular necrosis when applicable.
State patient activity expectations and anticipated longevity relative to a conventional prosthesis.

Documentation Required

Document clinical rationale and informed choice

Document the clinical rationale and informed-choice discussion: record patient-specific factors (age, activity level, contraindications to metal-on-metal implants) and counseling about risks (metallosis, pseudotumor, implant failure) and expected implant longevity.

Document that risks and benefits of metal-on-metal implants were discussed and the patient made an informed choice.
Record any contraindications to metal-on-metal devices considered in decision-making.

Billing Rule

Coding guidance for prior authorization

There is no specific CPT code for total hip resurfacing; for coding and prior authorization, total hip resurfacing may be reported with CPT 27130 or with an appropriate unlisted pelvis/hip joint code (HCPCS S2118 is listed). Provide diagnosis and, if inpatient, appropriate ICD-10-PCS codes as referenced.

Reported codes: CPT 27130 (total hip arthroplasty) or unlisted pelvis/hip joint; HCPCS S2118 listed for metal-on-metal total hip resurfacing.
Include ICD-10-CM diagnosis codes (M16.10-M16.9; M87.051-M87.059) and inpatient ICD-10-PCS codes if applicable.

Note

Frame resurfacing relative to THA in clinical justification

When selecting resurfacing, consider total hip resurfacing as the alternative to THA; the policy frames hip resurfacing as an alternative to conventional total hip replacement and implies THA should be considered as the comparator in decision-making.

Document rationale comparing expected outcomes and revision considerations versus conventional THA.

Note

Unspecified provider action

Not specified in this document.

Note

No provider actions specified here

Not specified in this document.

Step Therapy

Preference: total resurfacing over femoral-only partial resurfacing

Total hip resurfacing (femoral and acetabular components) is preferred over femoral-only partial resurfacing for younger patients without contraindications to metal-on-metal implants; document why partial resurfacing is chosen when it is proposed.

If proposing partial resurfacing, include justification that metal-on-metal prosthesis is contraindicated or not desired.
State that total resurfacing is preferred for younger patients when no contraindication exists.

Note

Unspecified provider action

Not specified in this document.

Prior Authorization

Verify eligibility and document that member meets policy criteria

Providers must identify member eligibility and document that the individual meets the policy criteria (candidate for THA, likely to outlive a traditional prosthesis, and no contraindication to resurfacing) and reference the member-specific benefit plan when requesting coverage.

Confirm member eligibility and cite the member-specific benefit plan in the submission.
Document that the patient meets all policy medical necessity criteria for the requested resurfacing type.

Documentation Required

Required clinical documentation for authorization

Required clinical documentation includes patient age, sex, BMI, bone quality, indication (e.g., osteoarthritis or avascular necrosis), prior conservative therapies, and implant type and rationale when resurfacing is chosen.

Provide radiographic and clinical evidence supporting diagnosis and extent of disease.
Document prior treatments and why resurfacing is indicated over alternative therapies.

Prior Authorization

Document AVN extent and suitability for partial resurfacing

For partial hip resurfacing prior authorization or documentation, specify avascular necrosis with no more than 50% femoral head involvement and that the patient is a younger, physically active candidate for whom bone preservation is a priority.

Include radiographic documentation quantifying femoral head involvement (≤50%).
Document why partial resurfacing is preferred due to contraindication to metal-on-metal total resurfacing.

Documentation Required

Suggested supporting documentation and long-term follow-up

Suggested supporting documentation for case selection includes reference to long-term follow-up data where available (minimum ~10 years for partial resurfacing) and citation of pertinent clinical trials or cohort evidence to support expected outcomes and implant longevity.

When applicable, reference long-term cohort or trial data (minimum ~10 years) to support anticipated durability.
Cite relevant ongoing or completed clinical trials if they inform the case.

Billing Rule

Coding guidance does not establish coverage

Coding guidance and example codes provided in the policy (CPT 27130, HCPCS S2118, unlisted codes, ICD-10-CM/PCS references) are for reference only and do not by themselves establish member coverage or guarantee reimbursement.

Inclusion of a code in the policy does not guarantee coverage; verify member-specific plan terms.

Denial Risk

Denial risk for procedures not meeting medical necessity

Procedures that do not meet the policy's medical necessity criteria (for example, patients who are not candidates for total hip replacement, are unlikely to outlive a traditional prosthesis, or have listed contraindications) may be denied.

Ensure medical necessity criteria in the Policy section are documented to avoid denial.

Denial Risk

Risk factors that may prompt denial or extra review

Patients with risk factors linked to higher failure rates—such as BMI >35 kg/m2, poor bone density, significant femoral head cysts, head-neck junction abnormalities, or female patients (especially postmenopausal or with decreased bone mineral density)—may trigger denial or require additional review.

Document and justify candidacy when one or more risk factors are present; provide additional evidence if applicable.

Denial Risk

Account for higher re-revision and long-term revision risks

Document that the increased re-revision and long-term revision risks reported after resurfacing revisions have been considered; these higher re-revision rates (for example, femoral-only re-revision rates vs primary THA) may affect coverage decisions for revisions or for populations with higher observed revision risk.

Include registry or cohort data rationale when selecting resurfacing in populations with known higher revision rates.

Denial Risk

Risk of denial if an inferior procedure (partial resurfacing) is chosen

Selection of partial hip resurfacing when total hip resurfacing is appropriate may be questioned because partial resurfacing has been associated with increased poor outcomes compared with total resurfacing; provide justification if partial resurfacing is proposed.

If proposing partial resurfacing, document specific contraindications to metal-on-metal total resurfacing and evidence supporting partial approach.

Billing Rule

Code inclusion does not assure coverage

Inclusion of specific procedure or diagnosis codes in the policy does not guarantee coverage; benefit determinations remain subject to the member-specific benefit plan documentation and the written coverage position in this medical policy.

Verify member plan terms even when codes align with the procedure requested.

inv-52: Partial hip resurfacing — intervention that resurfaces part of the femoral head (≤50% involvement)

Partial hip resurfacing — procedural definitionIntervention that resurfaces part of the femoral head; applicable when femoral head involvement is ≤50%

inv-53: Total hip resurfacing to total hip arthroplasty conversion — conversion definition

Conversion definitionConversion: revision surgery converting a prior hip resurfacing to a conventional total hip arthroplasty (THA)

inv-54: Partial hip resurfacing described as femoral-component-only procedure considered for osteonecrosis or when full resurfacing contraindicated

Partial (femoral-only) resurfacing clinical rolePartial hip resurfacing is a femoral-component-only resurfacing procedure considered for osteonecrosis or when full resurfacing is contraindicated

inv-55: Total hip resurfacing — metal-on-metal resurfacing involving femoral and acetabular components; risks and contraindications noted

Total hip resurfacing characteristics and risksMetal-on-metal resurfacing involves femoral and acetabular components; comparable to THA short-to-medium term but carries specific risks and contraindications (e.g., metallosis, pseudotumor, metal sensitivity)

inv-56: NCT — National Clinical Trial identifier used to reference ongoing/planned trials

NCT (trial identifier) usageNCT: National Clinical Trial identifier used to reference ongoing or planned clinical trials (examples: NCT00611585, NCT07080671)