Clinical UM Guideline


Subject: Elective Total Hip Arthroplasty
Guideline #:  CG-SURG-53 Publish Date:    08/29/2018
Status: Reviewed Last Review Date:    07/26/2018


This document addresses elective total hip arthroplasty (THA) for hip damage severe enough to require replacement, when performed as an elective, non-emergent procedure and not as part of the care of a congenital, acute or traumatic event such as fracture (excluding fracture of implant and periprosthetic fracture). This procedure is also referred to as total hip replacement (THR) surgery, where the femoral head and acetabulum are replaced with a prosthesis that is anchored to the bone.

Note: Please see the following related documents for additional information:

Clinical Indications

Medically Necessary:

Elective total hip arthroplasty is considered medically necessary when criteria are met for any of the following indications:

  1. Persistent, symptomatic degenerative joint disease (DJD), rheumatoid arthritis including juvenile rheumatoid arthritis/juvenile idiopathic arthritis (JRA/JIA) or hemophilic arthropathy as indicated by all of the following:
    1. Imaging evidence of significant joint destruction and cartilage loss (for example, hip joint destruction, severe narrowing, bone deformities); and
    2. Requires treatment as a result of disabling pain; and
    3. Individual has failed at least 3 months of non-surgical conservative therapy*; and
    4. Individual has limited hip function secondary to disease that interferes with ability to carry out age-appropriate activities of daily living (ADL); or
  2. Failure of prior hip fracture surgery; or
  3. Osteonecrosis (avascular necrosis) of femoral head confirmed by imaging evidence; or
  4. Revision of hip arthrodesis; or
  5. Primary or secondary tumors involving proximal femur confirmed by imaging evidence.

Elective revision of a previous total hip arthroplasty or prior hip resurfacing is considered medically necessary when there is documentation of one or more of the following present:

  1. Adverse local tissue or systemic reaction to previous metal implant; or
  2. Component instability, loosening, fracture of implant or other mechanical failure (for example, recurrent or irreducible dislocation, periprosthetic fracture); or
  3. Infection; or
  4. Progressive and substantial bone loss; or
  5. Recurrent disabling pain or significant functional disability that persists despite at least 3 months of conservative therapy* in conjunction with one of the following:
    1. An antalgic or Trendelenburg gait; or
    2. Abnormal findings confirmed by plain radiography or imaging studies.

*Note: Conservative therapy consists of an appropriate combination of medication (for example, non-steroidal anti-inflammatory drugs [NSAIDs], analgesics) and, in addition, injection (steroid), physical therapy, muscle strengthening, flexibility exercises, activity modification, weight loss, walking aids, bracing or other interventions based on the individual's specific presentation, physical findings and imaging results.

Not Medically Necessary:

Elective total hip arthroplasty, elective revision of a previous total hip arthroplasty or prior hip resurfacing is considered not medically necessary when the above criteria are not met and for all other indications, including but not limited to any of the following:

  1. Known allergy to implant components (for example, cobalt, nickel, or polyethylene);
  2. Presence of a skin infection at the surgical site;
  3. Presence of a systemic infection;
  4. Rapidly progressive neurological disease.

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.




Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft


Conversion of previous hip surgery to total hip arthroplasty, with or without autograft or allograft


Revision of total hip arthroplasty; both components, with or without autograft or allograft


Revision of total hip arthroplasty; acetabular component only, with or without autograft or allograft


Revision of total hip arthroplasty; femoral component only, with or without autograft or allograft



ICD-10 Procedure



Replacement of right hip joint, open approach[by device and cemented, uncemented or not specified; includes codes 0SR9019, 0SR901A, 0SR901Z, 0SR9029, 0SR902A, 0SR902Z, 0SR9039, 0SR903A, 0SR903Z, 0SR9049, 0SR904A, 0SR904Z]


Replacement of right hip joint with synthetic substitute, open approach [cemented, uncemented or not specified; includes codes 0SR90J9, 0SR90JA, 0SR90JZ]


Replacement of left hip joint, open approach[by device and cemented, uncemented or not specified; includes codes 0SRB019, 0SRB01A, 0SRB01Z, 0SRB029, 0SRB02A, 0SRB02Z, 0SRB039, 0SRB03A, 0SRB03Z, 0SRB049, 0SRB04A, 0SRB04Z]


Replacement of left hip joint with synthetic substitute, open approach [cemented, uncemented or not specified; includes codes 0SRB0J9, 0SRB0JA, 0SRB0JZ]


Revision of synthetic substitute in right hip joint [by approach; includes codes 0SW90JZ, 0SW93JZ, 0SW94JZ, 0SW9XJZ]


Revision of synthetic substitute in left hip joint [by approach; includes codes 0SWB0JZ, 0SWB3JZ, 0SWB4JZ, 0SWBXJZ]



ICD-10 Diagnosis



All diagnoses

Discussion/General Information

In the standard total hip replacement operation, the femoral head and neck are removed, and the femoral canal (marrow space) is reamed-out. The damaged hip joint is replaced with an artificial prosthesis composed of two or three different components: 1) the head, (a metal ball, for example, stainless steel or cobalt chrome) that replaces the original femoral head, 2) the femoral component (a metal stem placed into the femur) and 3) the acetabular component (a plastic cup made of high-density polyethylene) that is implanted into the acetabulum. The stem may be secured using bone cement or press-fit for the bone to grow into it.

Hip replacement surgery is one of the most frequently performed inpatient procedures in the United States. According to the Centers for Disease Control and Prevention, nearly 332,000 THAs are performed annually in the United States (CDC, 2010). This number is expected to grow as the population ages. The vast majority of cases of THAs are due to degenerative joint disease, also known as osteoarthritis (OA). Approximately 14% of U.S. adults will be affected by OA during their lifetime. The rate of affected adults increases to 33.6% in those aged 65 years and older. However, OA does not always progress to the point where surgery is recommended; the need for elective THR surgery is limited to individuals who present with pain, impaired function interfering with ADLs, imaging evidence of significant joint destruction and cartilage loss, and failed conservative therapy. While OA progression cannot be reversed, conservative treatment can frequently slow or mitigate the progression of the disease. THA when done electively aims to re-establish functional joint movement and alleviate chronic joint pain associated with hip damage due to degenerative joint disease. Elective arthroplasty is used for reconstruction of a damaged hip joint resulting in refractory chronic joint pain or functional disability and to enhance quality of life. While hemophilia arthropathy is not a common condition, the hip joint can be affected by the disease. Bleeding into joints causes progressive damage to the articular cartilage leading to cartilage loss, pain and loss of function. These changes may ultimately lead to hip arthroplasty if conservative measures fail to alleviate symptoms.

The diagnosis of OA typically is made with the combination of clinical examination, laboratory testing and radiologic assessment, with x-ray images considered the gold standard in identifying OA and evaluating severity of disease. There several radiographic scoring systems which classify the extent of joint damage based upon pathophysiological joint signs visualized on radiographic images. Significant joint destruction can typically be visualized on radiological exams as subchondral cysts, subchondral sclerosis, osteophytes (bone spurs), joint narrowing, joint malalignment or subluxation, bone attrition or osteonecrosis.

Rheumatoid arthritis is a chronic inflammatory and progressive disease characterized by symmetrical joint involvement, which causes pain, swelling, stiffness, and loss of function in the joints. If left untreated, it may lead to joint destruction and progressive disability. Rheumatoid arthritis affects 2.1 million Americans usually striking people between the ages of 20 and 60, and people in their mid to late fifties are especially vulnerable. Rheumatoid arthritis is three times more common in women than in men. The traditional nonsurgical approach consists of non-steroidal anti-inflammatory drugs (NSAIDs) to reduce pain, swelling, and inflammation, plus a disease-modifying antirheumatic drug (DMARD) such as methotrexate to slow the course of the disease and prevent joint and cartilage destruction, physical therapy, or assistive devices. Total hip arthroplasty is considered for individuals who have exhausted other conservative treatment options (AAOS, 2014).

Juvenile idiopathic arthritis (JIA), also known as juvenile rheumatoid arthritis (JRA), commonly occurs in children between ages 7 and 12 years old. JRA affects an estimated 300,000 children in the United States and approximately 1 in every 1,000 children develop some type of juvenile arthritis. In a study examining the arthroplasty rates between 1991 and 2005, Mertelsmann-Voss and associates (2014) noted that the rates of arthroplasty in the JIA population have significantly decreased. The authors suggest this decrease might be due to the effectiveness of DMARDs and biologic agents in preventing end-stage joint destruction if initiated early in the disease process. THA procedures in this population can be complex, structural abnormalities may exist, bone quality is frequently compromised, multiple joint involvement is common and due to the small size proportions, limiting implant options. This may contribute to poorer long term outcomes. THA provides an alternative for children with JRA who have failed medical treatment.

An elective THA may be considered as an option among other alternatives, weighing the potential risks and benefits prior to proceeding with total hip replacement. Complications associated with THA include deep venous thrombosis, pulmonary embolus, deep prosthetic infection, or periprosthetic fracture. Less than 1.0% of individuals undergoing THA die within the 30 day post-operative period. Approximately 10% of those who undergo THA will continue to experience residual pain for 6 or more months following surgery. A number of conservative interventions have been shown to be effective in controlling the symptoms of OA.

The OA Research Society International (OARSI) published recommendations in 2008 on the management of hip osteoarthritis recommending that orthopaedic surgical intervention proceed after more conservative treatment options were exhausted. Conservative treatments recommended include pharmacological interventions, such as capsaicin, paracetamol (acetaminophen), topical and oral non-selective non-steroidal anti-inflammatory drugs (NSAIDS), oral COX-2 inhibitors, and intra-articular glucocorticoids. OARSI recommended several core treatments appropriate for all individuals including but not limited to:

In 2012, the American College of Rheumatology (ACR) published updated recommendations for the use of nonpharmacologic and pharmacologic therapies in OA of the hip, including cardiovascular (land based or aquatic) and resistance exercise as well as weight loss in those who are overweight and the use of one of the following: oral or topical NSAIDS, Tramadol or intra-articular corticosteroid injections in those individuals who have failed full dose acetaminophen therapy.

Obesity is an independent risk factor for multiple diseases including joint deterioration (Perry, 2016). Within the overall population, the increase in the incidence of total joint arthroplasty parallels the rising rate of obesity. There is a general consensus that the risk of short term post-operative complications increases as weight increases, including wound infections, component malposition and in-hospital mortality (Perry, 2016). There does appear to be an increased revision rate for overweight or obese individuals five or more years following the initial surgery although this risk appears to be only moderately higher (Perry, 2016). Obese individuals have reported equivalent or superior clinical outcome satisfaction scores (Perry, 2016). There appears to be few options for those individuals with DJD who are overweight or obese. Smith and colleagues (2016) noted that those individuals with OA are at a greater risk of gaining weight due to reduced activity. While the authors of many of the studies recognized the increased complexity related to performing THAs on this population, the majority of studies recommended not withholding joint replacement surgery for overweight or obese individuals (Perry, 2016; Suleiman, 2012). The American Association of Hip and Knee Surgeons (2013) notes that TKA may be considered in obese individuals and states “expectations are for a steady, but slower improvement in the severe obese compared to non-obese patients post operatively”.

The World Federation of Hemophilia 2012 guidelines for the management of hemophilia recommend a similar treatment plan for those affected with chronic hemophilic arthropathy. Recommended conservative therapies include analgesics such as COX-2 inhibitors, physiotherapy to preserve strength and function, casting, bracing, orthotics, walking aids or home or activity modifications. If conservative treatment fails, joint replacement surgery might be needed for severe disease.


Activities of daily living (ADLs): Self-care activities such as transfers, toileting, grooming and hygiene, dressing, bathing, and eating.

Arthroplasty: Surgical replacement of all or part of a joint.

Degenerative joint disease (DJD): A progressive disorder of the joints caused by gradual loss of cartilage.

Osteoarthritis (OA): Also known as osteoarthrosis, is a form of DJD.

Rheumatoid arthritis: A chronic inflammatory arthritis, the synovium thickens; causing swelling and produces chemical substances that attaches and destroys the articular cartilage covering the bone.

Range of motion (ROM): Measurement of the extent to which a joint can go through all its normal spectrum of movements.


Peer Reviewed Publications:

  1. Altman R, Asch E, Bloch D, et al. Development of criteria for the classification and reporting of osteoarthritis. Classification of osteoarthritis of the knee. Diagnostic and Therapeutic Criteria Committee of the American Rheumatism Association. Arthritis Rheum. 1986; 29(8):1039-1049.
  2. Beaule PE, Matta JM, Mast JW. Hip arthrodesis: current indications and techniques. J AM Acad Orthop Surg. 2002; 10(4):249-528.
  3. Dreinhofer KE, Dieppe P, Sturmer T, et al. Indications for total hip replacement: comparison of assessments of orthopaedic surgeons and referring physicians. 2006; 65(10):1346-1350.
  4. Golightly YM, Allen KD, Caine DJ. A comprehensive review of the effectiveness of different exercise programs for patients with osteoarthritis. Phys Sportsmed. 2012; 40(4):52-65.
  5. Goodman SB, Hwang K, Imrie S. High complication rate in revision total hip arthroplasty in juvenile idiopathic arthritis. Clin Orthrop Relat Res. 2014; 472:637-644.
  6. Gross TP, Liu F. Outcomes after revision of metal-on-metal hip resurfacing arthroplasty. J Arthroplasty. 2014; 29(9 Suppl):219-223.
  7. Hamilton D, Henderson GR, Gaston P, et al. Comparative outcomes of total hip and knee arthroplasty: a prospective cohort study. Postgrad Med J. 2012; 88(1045):627-631.
  8. Haidukewych GJ, Langford J, Liporace FA. Revision for periprosthetic fractures of the hip and knee. J Bone Joint Surg. 2013; 95(4):368-376.
  9. Haverkamp D, Klinkenbijl MN, Somford MP, et al. Obesity in total hip arthroplasty- does it really matter? A meta-analysis. Acta Orthopaedica. 2011; 82(4):417-422.
  10. Jacobs JJ, Mont MA, Bozic KJ, et al. American Academy of Orthopaedic Surgeons clinical practice guideline on: preventing venous thromboembolic disease in patients undergoing elective hip and knee arthroplasty. J Bone Joint Surg Am. 2012; 94(8):746-747.
  11. Kim C, Nevitt MC, Niu J, et al. Association of hip pain with radiographic evidence of hip osteoarthritis: diagnostic test study. BMJ. 2015; 351:h5983.
  12. Kurtz S, Ong K, Lau E, et al. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007; 89(4):780-785.
  13. Latham N, Liu CJ. Strength training in older adults: the benefits for osteoarthritis. Clin Geriatr Med. 2010; 26(3): 445-459.
  14. Mak JC, Fransen M, Jennings M, et al. Evidence-based review for patients undergoing elective hip and knee replacement. ANZ J Surg. 2014; 84(1-2):17-24.
  15. Mahomed NN, Koo Seen Lin MJ, Levesque J, et al. Determinants and outcomes of inpatient versus home based rehabilitation following elective hip and knee replacement. J Rheumatol. 2000; 27(7):1753-1758.
  16. McCalden RW, Charron KD, MacDonald SJ, et al. Does morbid obesity affect the outcome of total hip replacement? J Bone Joint Surg. 2011; 93:321-325.
  17. Mertelsmann-Voss C, Lyman S, Pan TJ, et al. US trends in rates of arthroplasty for inflammatory arthritis including rheumatoid arthritis, juvenile idiopathic arthritis, and spondyloarthritis. Arthritis Rheumatol. 2014; 66(6):1432-1439.
  18. Pereira D, Peleteiro B, Araújo J, et al. The effect of osteoarthritis definition on prevalence and incidence estimates: a systematic review. Osteoarthritis Cartilage. 2011; 19(11):1270-1285.
  19. Perry KI, MacDonald SJ. The obese patient: a problem of larger consequence. Bone Joint J. 2016; 98-B(1 Suppl A):3-5.
  20. Pivec R, Johnson AJ, Mears SC, Mont MA. Hip arthroplasty. Lancet 2012; 380(9855):1768-1777.
  21. Queally JM, Abdulkarim A, Mulhall KJ. Total hip replacement in patients with neurological conditions. J Bone Joint Surg. 2009; 91(8):1267-1273.
  22. Quintana JM, Escobar A, Arostegui I, et al. Health-related quality of life and appropriateness of knee or hip joint replacement. Arch Intern Med. 2006; 166(2):220-226.
  23. Santaguida P. Hawker G. Hudak PL, et al. Patient characteristics affecting the prognosis of total hip and knee joint arthroplasty: a systematic review. Can J Surg. 2008; 51(6):428-436.
  24. Smith TO, Aboelmagd T, Hing CB, MacGregor A. Does bariatric surgery prior to total hip or knee arthroplasty reduce post-operative complications and improve clinical outcomes for obese patients? Systematic review and meta-analysis. Bone Joint J. 2016; 98-B(9):1160-1166.
  25. Suleiman LI, Ortega G, Ong'uti SK, et al. Does BMI affect perioperative complications following total knee and hip arthroplasty? J Surg Res. 2012; 174(1):7-11.
  26. Tsang ST, Gaston P. Adverse peri-operative outcomes following elective total hip replacement in diabetes mellitus: a systematic review and meta-analysis of cohort studies. Bone Joint J. 2013; 95(11):1474-1479.
  27. Tsertsvadze A, Grover A, Freeman K, et al. Total hip replacement for the treatment of end stage arthritis of the hip: a systematic review and meta-analysis. PLos ONE. 2014; 9(7):e99804.
  28. Vincent KR, Lee LW, Weng J, et al. A preliminary examination of the CMS eligibility criteria in total-joint arthroplasty. Am J Phys Med Rehabil. 2006; 85(11):872-881.
  29. Wagner ER, Kamath AF, Fruth KM, et al. Effect of body mass index on complications and reoperations after total hip arthroplasty. J Bone Joint Surg Am. 2016; 98:169-179.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Academy of Orthopaedic Surgeons (AAOS). American Academy of Orthopaedic Surgeons clinical practice guideline on preventing venous thromboembolic disease in patients undergoing elective hip and knee arthroplasty. Revised 2011. Available at: Accessed on June 04, 2018.
  2. American Academy of Orthopaedic Surgeons (AAOS). Management of hip fractures in the elderly: Evidence-Based Clinical Practice Guideline. Adopted September 5, 2015. Available at: Accessed on June 04, 2018.
  3. American Academy of Orthopaedic Surgeons (AAOS). The diagnosis of periprosthetic joint infections of the hip and knee. Guideline and evidence report. June 2010. Available at: Accessed on June 04, 2018.
  4. American Joint Replacement Registry (AJRR). Annual report 2016. Available at: Accessed on June 04, 2018.
  5. First Coast Service Options, Inc. Jurisdiction J-N. Local Coverage Determination for Major Joint Replacement (Hip and Knee) (L33618). Revised 2/15/2018. Available at: Available at: Accessed on June 04, 2018.
  6. Hochberg MC, Altman RD, April KT, et al.; American College of Rheumatology. American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care Res. 2012; 64(4):465-474.
  7. Jolles BM, Bogoch ER. Posterior versus lateral surgical approach for total hip arthroplasty in adults with osteoarthritis. Cochrane Database Syst Rev. 2006;(3):CD003828.
  8. Kahn RJK, Carey Smith RL, Alakerson R, et al. Operative and non-operative treatment options for dislocation of the hip following total hip arthroplasty. Cochrane Database Syst Rev. 2006; (4):CD005320.
  9. National Government Services, Inc. Jurisdiction Illinois. Local Coverage Determination for Total Joint Arthroplasty (L36039). Revised 12/01/2015. Available at: Accessed on June 04, 2018.
  10. Nelson AE, Allen KD, Golightly YM, et al. A systematic review of recommendations and guidelines for the management of osteoarthritis: the chronic osteoarthritis management initiative of the U.S. bone and joint initiative. Semin Arthritis Rheum. 2014; 43(6):701-712.
  11. Osmon DR, Berbari EF, Berendt AR, et al; Infectious Diseases Society of America. Diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2013; 56(1):e1-e25.
  12. Workgroup of the American Association of Hip and Knee Surgeons Evidence Based Committee. Obesity and total joint arthroplasty: a literature based review. J Arthroplasty. 2013; 28(5):714-721.
  13. World Federation of Hemophilia. Guidelines for the management of hemophilia: 2nd edition. 2012. Available at: Accessed on June 04, 2018.
  14. Zhang W, Moskowitz RW, Nuki G, et al. Osteoarthritis Research Society International (OARSI) recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis Cartilage. 2008; 16(2):137-162.
Websites for Additional Information
  1. American Academy of Orthopaedic Surgeons. OrthoInfo: Inflammatory arthritis of the hip. July 2014. Available at: Accessed on June 04, 2018.
  2. American College of Rheumatology (ACR). Juvenile Arthritis. Updated June 2015. Available at: Accessed on June 04, 2018.
  3. American Academy of Orthopaedic Surgeons. OrthoInfo: Total hip replacement. August 2015. Available at: Accessed on June 04, 2018.
  4. Centers for Disease Control and Prevention (CDC). Arthritis. May 11, 2018. Available at: Accessed on June 04, 2018.
  5. Hemophilia Federation of America (HFA). Joint Damage. Available at: Accessed on June 04, 2018.
  6. National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS). Joint Replacement Surgery. Available at: Accessed on June 04, 2018.
  7. U.S. National Library of Medicine Medline Plus. Hip Replacement. Bethesda, MD. Last updated on August 31, 2016. Available at: Accessed on June 04, 2018.

Total Hip Arthroplasty
Total Hip Replacement

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Medical Policy & Technology Assessment Committee (MPTAC) review. Updated References and Websites sections.



MPTAC review. Updated References and Websites sections. The document header wording updated from “Current Effective Date” to “Publish Date.”



MPTAC review. Updated References and Websites sections.



MPTAC review. Updated formatting in Clinical Indications section. Updated References and Websites sections.



MPTAC review. Added juvenile rheumatoid arthritis to the MN indications. Updated formatting in position statements. Revised MN clinical indications for elective revision of a previous total hip arthroplasty or prior hip resurfacing. Updated References and Websites sections.



MPTAC review. Updated References and Websites sections.



MPTAC review. Initial document development.