CurrentuniverahealthcarePolicy 7.01.74

Metal-on-Metal Total Hip Resurfacing

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Policy governs medical necessity criteria and exclusions for FDA‑approved metal-on-metal total hip resurfacing devices for members, specifying clinical, imaging, age, and prior non-surgical management requirements.

Policy Summary

Payeruniverahealthcare

PolicyMetal-on-Metal Total Hip Resurfacing

Policy CodePolicy 7.01.74

Change TypeNo material change

Effective DateOct 15, 2026

Last ReviewJun 18, 2026

Next Review DateJun 1, 2027

Key ActionObtain prior authorization confirming age ≤64, qualifying imaging, function‑limiting pain and failure of ≥3 months of provider-directed non-surgical management (or documented exception).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≤64maximum age for coverage

3 mominimum non-surgical management

<=50%AVN femoral head limit

S2118HCPCS code

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CurrentuniverahealthcarePolicy 7.01.74

Metal-on-Metal Total Hip Resurfacing

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Policy Summary

Payeruniverahealthcare

PolicyMetal-on-Metal Total Hip Resurfacing

Policy CodePolicy 7.01.74

Change TypeNo material change

Effective DateOct 15, 2026

Last ReviewJun 18, 2026

Next Review DateJun 1, 2027

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≤64maximum age for coverage

3 mominimum non-surgical management

<=50%AVN femoral head limit

S2118HCPCS code

NICE 10yr revision benchmark

Medical Necessity and Exclusions

Medical necessity criteria for metal-on-metal total hip resurfacing

Covered when ALL of the following are met

Overall coverage rule: HRA using an FDA-approved device is medically appropriate when ALL criteria below are met

Age: Individual is age 64 years or younger<=64 years

Imaging shows EITHER: osteoarthritis or inflammatory arthritis affecting BOTH the femoral head and the acetabulum with joint space narrowing on weight-bearing radiographs; OR avascular necrosis of the femoral head with possible acetabular involvement and less than 50% involvement of the femoral headavascular necrosis <50%

Symptoms: Both: function-limiting pain at short distances (e.g., walking <1/4 mile or ~2 city blocks) for at least 3 months; AND loss of hip function interfering with age-appropriate activities of daily living>=3 months

Three-month symptom duration is not required if the medical record documents why provider-directed non-surgical management is inappropriate (e.g., collapse of the femoral head, inflammatory arthritis, advanced dysplasia).

Prior non-surgical management: Failure of provider-directed non-surgical management for at least 3 months duration>=3 months

Provider-directed non-surgical management may be inappropriate; the medical record must clearly document the reason (examples: collapse of the femoral head, inflammatory arthritis, advanced dysplasia).

Covered population and explicit non-covered conditions

Policy statements and clinical selection context

Not medically necessary conditions: Metal-on-metal total hip resurfacing is not medically necessary for individuals with known or suspected metal sensitivity

explicit non-covered statement

Not medically necessary - childbearing potential: Metal-on-metal total hip resurfacing is not medically necessary for individuals of childbearing potential due to unknown effects of metal ion release on the fetus

explicit non-covered statement

Typical candidate description: Total hip resurfacing is described as an alternative for younger, active individuals less than 65 years old with hip disease such as osteoarthritis, rheumatoid arthritis, or advanced avascular necrosis

Clinical context and selection preference; not an additional mandatory coverage criterion in this policy excerpt.

Metal-on-metal total hip resurfacing is not medically necessary for any other condition or contraindication including, but not limited to: evidence of avascular necrosis of the femoral head with >50% involvement; skeletally immature individuals; active local or systemic infection; vascular insufficiency, significant muscular atrophy or severe neuromuscular disease compromising implant stability or recovery; Charcot joint; individuals undergoing dialysis and on a renal transplant list; inadequate bone stock to support the device; severe overweight; and immunosuppression or receipt of high doses of corticosteroids.

Metal-on-metal total hip resurfacing is not medically necessary for individuals with known or suspected metal sensitivity. It is also not medically necessary for individuals of childbearing potential because the effects of metal ion release on the fetus are unknown.

Coverage of metal-on-metal total hip resurfacing is product dependent. If a member’s product does not cover the service, the medical policy criteria do not apply; when a product does cover the service, the policy criteria govern benefit applicability unless superseded by Medicaid (eMedNY) or a national/local Medicare coverage decision.

The policy’s exclusions reinforce the non-covered conditions: HRA is not medically necessary for listed contraindications including >50% femoral head avascular necrosis, skeletally immature status, active infection, inadequate bone stock, severe overweight, immunosuppression/high-dose corticosteroid use, known or suspected metal sensitivity, and individuals of childbearing potential.

In summary, when any of the explicit exclusion criteria are present — for example, extensive avascular necrosis (>50% femoral head involvement), active infection, inadequate bone stock, known/suspected metal sensitivity, or childbearing potential — metal-on-metal total hip resurfacing is considered not medically necessary and requests are at risk of denial.

Avascular necrosis femoral head involvement — threshold/value pair

AVN femoral head involvement≤ 50% of femoral head involvement required to be eligible (AVN with more than 50% involvement is a contraindication)

Imaging requirementAvascular necrosis must be documented on imaging; possible acetabular involvement allowed

Exclusion trigger>50% femoral head AVN listed as not medically necessary

Age — maximum age threshold for coverage

Maximum age for coverageIndividual is age 64 years or younger

Typical candidate contextProcedure described as alternative for younger, active individuals less than 65 years

Age as prior-auth criterionPrior authorization requires confirmation that patient is ≤64 years

Non-surgical management / symptom duration requirement

Minimum symptom durationFunction‑limiting pain for at least 3 months (e.g., walking <1/4 mile or ~2 city blocks)

Non-surgical management failureFailure of provider-directed non-surgical management for at least 3 months is required (exceptions allowed with documentation)

Examples of non-surgical careRelative rest/activity modification, weight loss, supervised physiotherapy, medications, assistive devices, intra‑articular injections

Implant 10-year revision rate benchmark referenced (NICE)

NICE 10‑year revision benchmarkProstheses should have a revision rate of 5% or less at 10 years (NICE benchmark referenced)

Relevance to device selectionNICE recommended the same revision‑rate standard for resurfacing as for THA when both are suitable

Prior authorization noteCoverage review may consider device revision‑rate benchmarks when evaluating requests

Relevant Codes and Clinical Code-Adjunct Values

HCPCS CodesHCPCS

S2118

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

ICD-10 CodesICD-10

M16.0-M16.9	Osteoarthritis of hip (code range)
M87.050	Idiopathic aseptic necrosis of pelvis
M87.051-M87.059	Idiopathic aseptic necrosis of femur (code range)
M87.150-M87.159	Osteonecrosis due to drugs, pelvis/femur (code range)
M87.250-M87.259	Osteonecrosis due to previous trauma, pelvis/femur (code range)
M87.351-M87.359	Other secondary osteonecrosis, femur (code range) / other osteonecrosis pelvis/femur ranges

Avascular necrosis femoral head involvement (duplicate placement for coding visibility)

AVN femoral head involvement≤ 50% of femoral head involvement required to be eligible (AVN with more than 50% involvement is a contraindication)

Imaging documentationAVN must be shown on imaging; acetabular involvement may be present

Denial riskRequests with >50% femoral head AVN are at risk of denial

Age (duplicate placement for coding visibility)

Maximum age64 years or younger required for coverage

Clinical noteDescribed as suitable for individuals <65 years, but age criterion in policy is ≤64

Prior Authorization, Documentation, and Denial Risks

Prior Authorization

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

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.

Clinical Context and Rationale

Total hip resurfacing (HRA) is presented as a bone-conserving surgical alternative to total hip arthroplasty for younger, active individuals (typically <65 years) with hip disease such as osteoarthritis, inflammatory arthritis, or advanced avascular necrosis. The procedure resurfaces the femoral head with a hollow metal hemisphere that articulates with a metal acetabular cup, aiming to preserve proximal femoral bone stock and provide a large-diameter articulation that may improve stability and range of motion; preservation of bone stock can facilitate future conversion to total hip replacement.

Key Terms

Hip resurfacing arthroplasty (HRA) definition

HRA definitionA surgical procedure that trims and covers the femoral head with a hollow metal hemisphere that articulates with a metal acetabular cup, preserving proximal femoral bone stock

IndicationsIndicated for disease affecting both the femoral head and acetabulum or AVN with limited femoral head involvement

Potential advantageMay facilitate future total hip replacement by conserving femoral bone stock and offering large‑diameter articulation for stability

Total hip resurfacing definition

Total hip resurfacingA bone‑conserving surgical procedure in which the femoral head surface is trimmed and covered with a hollow metal hemisphere that fits into a metal acetabular cup

Clinical goal

Policy History and Review Dates

2026-06-18Committee approval / annual reviewLatest

Committee approval (policy review) recorded on 06/18/26 as part of routine annual review; policy history lists committee dates through 06/18/26.

2025-06-26Annual review

Annual review performed; summary notes an annual review with Policy Statement updated to include additional FDA information on 06/26/25.

2024-06-20

Policy Summary

Payeruniverahealthcare

PolicyMetal-on-Metal Total Hip Resurfacing

Policy CodePolicy 7.01.74

Change TypeNo material change

Effective DateOct 15, 2026

Last ReviewJun 18, 2026

Next Review DateJun 1, 2027

SourceLink

On This Page

Conservative management prior to resurfacing:

Non-surgical management (relative rest/activity modification, weight loss, supervised physiotherapy and therapeutic exercises, oral medications, assistive devices, and/or intra-articular injections) is reasonable care prior to considering surgical resurfacing

Descriptive guidance from policy text; failure of provider-directed non-surgical management for ≥3 months is required for coverage unless documented as inappropriate.

Authorization requirementPrior authorization must confirm patient's age is within threshold

Non-surgical management / symptom duration (coding-context key value)

Symptom duration prerequisiteFunction‑limiting pain for ≥3 months required

Non-surgical trialFailure of provider-directed non-surgical management for at least 3 months unless documented as inappropriate

Documentation examplesRecord types of non-surgical care attempted and rationale if exceptions applied

Implant 10-year revision rate (coding-context key value)

10‑year revision‑rate threshold5% or less revision rate at 10 years (NICE benchmark)

Policy applicationNICE advised using 5% at 10 years as the revision‑rate standard when selecting resurfacing prostheses

Coding/prior auth relevanceDevice selection and prior authorization review may reference revision‑rate performance

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

Prior Authorization

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.

Step Therapy

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.

Note

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.

Documentation Required

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.

Documentation Required

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.

Note

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.

Denial Risk

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.

Denial Risk

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.

Billing Rule

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.

Documentation Required

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.

Preserves proximal femoral bone stock and may allow later conversion to total hip arthroplasty if required

Patient profileDescribed as an alternative for younger, active individuals (<65 years) with hip disease

Metal-on-metal (MoM) resurfacing devices definition

MoM device compositionResurfacing implants composed of cobalt‑chromium or similar metal alloys for both femoral and acetabular bearing surfaces

Regulatory requirementAll resurfacing devices and components require FDA approval prior to marketing and use in the U.S.

Examples of approved systemsBirmingham Hip Resurfacing (BHR), Cormet Hip Resurfacing, Conserve Plus (listed in regulatory section)

Distinction: Total hip resurfacing vs total hip arthroplasty (literature/regulatory considerations)

Procedural distinctionTotal hip resurfacing conserves proximal femoral bone stock by resurfacing rather than removing the femoral head and canal as in THA

Outcome and device considerationsLiterature and guidelines reference distinct device performance and revision‑rate outcomes for resurfacing versus THA (NICE recommended same 10‑year revision threshold)

Regulatory contextDevices for resurfacing are regulated separately; device approvals (eg, BHR, Cormet) and surveillance are relevant to clinical selection

Committee approval recorded on 06/20/24 as part of the policy history timeline.

2023-04-20Committee approval

Committee approval recorded on 04/20/23 as part of the policy history timeline.

2022-04-21Committee approval

Committee approval recorded on 04/21/22 as part of the policy history timeline.

2021-04-15Committee approval

Committee approval recorded on 04/15/21 as part of the policy history timeline.

2020-08-20Committee approval

Committee approval recorded on 08/20/20 as part of the policy history timeline.

2018-12-20Committee approval

Committee approval recorded on 12/20/18 as part of the policy history timeline.

2018-06-21Committee approval

Committee approval recorded on 06/21/18 as part of the policy history timeline.

2018-01-18Committee approval

Committee approval recorded on 01/18/18 as part of the policy history timeline.

2017-01-19Committee approval

Committee approval recorded on 01/19/17 as part of the policy history timeline.

2016-01-21Committee approval

Committee approval recorded on 01/21/16 as part of the policy history timeline.

2015-01-22Committee approval

Committee approval recorded on 01/22/15 as part of the policy history timeline.

2014-02-20Committee approval

Committee approval recorded on 02/20/14 as part of the policy history timeline.

2013-02-21Committee approval

Committee approval recorded on 02/21/13 as part of the policy history timeline.

2012-02-16Committee approval

Committee approval recorded on 02/16/12 as part of the policy history timeline.

2011-02-17Committee approval

Committee approval recorded on 02/17/11 as part of the policy history timeline.

2010-03-18Committee approval

Committee approval recorded on 03/18/10 as part of the policy history timeline.

2009-04-16Committee approval

Committee approval recorded on 04/16/09 as part of the policy history timeline.

2008-05-14Committee approval

Committee approval recorded on 05/14/08 as part of the policy history timeline.

2007-07-19Committee approval

Committee approval recorded on 07/19/07 as part of the policy history timeline.

2006-06-15Committee approval

Committee approval recorded on 06/15/06 as the earliest committee date listed in the policy history.