Prior authorization required to verify medical necessity

Prior authorization is required to confirm that all medical necessity criteria are met, including patient age ≤64 years, imaging consistent with osteoarthritis/inflammatory arthritis affecting both the femoral head and acetabulum or avascular necrosis with <50% femoral head involvement, function‑limiting pain and loss of hip function, and failure of ≥3 months of provider‑directed non‑surgical management (unless an exception is documented).

• PA must document age (≤64 years).
• PA must include imaging demonstrating the required radiographic findings.
• PA must document symptom duration/functional impact and prior non‑surgical management or rationale for exception.

Prior authorization / code requirement — HCPCS S2118

Include HCPCS code S2118 on authorization requests for metal‑on‑metal total hip resurfacing; coverage determinations will be reviewed against policy criteria and device outcome benchmarks.

• Use HCPCS S2118: Metal‑on‑metal total hip resurfacing, including acetabular and femoral components.

Product-dependent coverage — verify member product benefits

Verify the member's product benefits before submitting a request; coverage and the applicability of medical policy criteria depend on the member's commercial, Medicaid, or Medicare product.

• If a Medicare HMO‑DSNP product does not cover the service, refer to the Medicaid product coverage line as instructed.
• If a product does not cover the service, medical policy criteria do not apply.

Non-surgical management prerequisite — 3 months required unless exception documented

Document failure of provider‑directed non‑surgical management for at least three (3) months prior to approval; if non‑surgical management is inappropriate, the medical record must clearly document the reason (e.g., femoral head collapse, inflammatory arthritis, advanced dysplasia).

• Record types of non‑surgical treatments attempted and duration (≥3 months).
• If exempting the 3‑month requirement, include specific clinical justification in the record.

Conservative management prior to resurfacing — HRA as alternative in younger active individuals

Consider total hip resurfacing as a bone‑conserving surgical alternative to total hip arthroplasty for younger, active individuals (<65 years) after conservative (non‑surgical) treatments have been tried and documented.

• Document discussion of alternatives, including watchful waiting and total hip arthroplasty, and rationale for choosing resurfacing.

Required clinical documentation — device approval, pain duration/impact, prior management

Provide clinical documentation showing the device used is FDA‑approved, the duration and functional impact of pain (typically ≥3 months), failure of provider‑directed non‑surgical management (or documented rationale for inappropriateness), and preoperative optimization of modifiable medical and behavioral comorbidities.

• Include device make/model and evidence of FDA approval.
• Detail symptom duration, walking distance limits, and activities of daily living affected.
• List non‑surgical therapies attempted and dates.

Device regulatory status — confirm FDA approval prior to use

Confirm FDA approval status for the resurfacing device to be used; all resurfacing devices and related components require FDA approval prior to marketing and use in the United States.

• Reference the FDA Medical Device website or approval documentation for the specific implant.
• Note approved devices listed in policy (e.g., Birmingham Hip Resurfacing, Cormet, Conserve Plus) when applicable.

Commercial/Medicaid/Medicare product guidance — apply contract-dependent rules

When policy application differs by product type, document which product covers the service and apply the corresponding guidance; medical policy criteria apply when the commercial, Medicaid (without eMedNY guidance), or Medicare product covers the service and no specific Medicare decision exists.

• Verify product-level coverage before relying on policy criteria.
• Follow Medicaid or Medicare instructions if product coverage or coverage decisions differ.

Exclusion-based denial triggers — requests at risk if listed contraindications present

Requests are at risk of denial if the member has any listed contraindication or exclusion, including avascular necrosis with more than 50% femoral head involvement, skeletally immature status, active infection, inadequate bone stock, severe overweight, immunosuppression/high‑dose corticosteroids, vascular insufficiency or severe neuromuscular disease, Charcot joint, or dialysis/on renal transplant list.

• Evaluate preoperative imaging and medical history for these exclusions.
• If exclusions are present, do not submit authorization request or expect denial unless mitigating documentation is provided.

Explicit non-covered indications — metal sensitivity and childbearing potential

Do not pursue resurfacing for individuals with known or suspected metal sensitivity or for individuals of childbearing potential; these are explicitly stated as not medically necessary.

• Document any history or testing related to metal sensitivity; absence does not imply clearance.
• Confirm and document reproductive status; individuals of childbearing potential are excluded.

Services are contract dependent — verify member product before requesting

Services may be contract dependent; verify the member's product because if a product does not cover this service, the policy criteria do not apply and the request may be denied.

• Check benefit plan exclusions before submitting authorization.
• If a Medicare HMO‑DSNP product does not cover the service, follow the policy's instruction to refer to the Medicaid product coverage line.

Provider action — assemble complete authorization documentation (high‑importance guidance)

Provide concise, actionable documentation for authorization: include patient age, weight‑bearing radiographs with joint space description or AVN percentage (<50% if present), symptom duration and functional limitations, detailed record of non‑surgical treatments tried (with dates), device identity and FDA approval evidence, and preoperative optimization notes.

• Attach weight‑bearing radiographs and radiology report documenting joint space narrowing or AVN involvement percentage.
• List dates and specifics of non‑surgical therapies and reasons if exceptions to the 3‑month rule are claimed.
• Include device FDA approval documentation and notes on modifiable comorbidity optimization.