Metal-on-Metal Total Hip Resurfacing 7.01.74

By October 15, 2025: (1) Billing team must implement pre-authorization workflow requiring providers to document ALL mandatory criteria before submitting claims for metal-on-metal hip resurfacing: patient age ≤64 years, imaging findings (osteoarthritis with joint space narrowing OR AVN <50% involvement), function-limiting pain ≤¼ mile for 3+ months, loss of hip function affecting ADLs, and 3+ months of failed non-surgical management (with documented exceptions per policy). (2) Update billing system and encounter forms to flag claims missing any required documentation element. (3) Educate orthopedic surgeons and physician assistants on 10 contraindications listed in Section II (AVN >50%, skeletally immature, active infection, vascular insufficiency, Charcot joint, dialysis/transplant list, inadequate bone stock, severely overweight, immunosuppressed/high-dose corticosteroids, known/suspected metal sensitivity, childbearing potential). (4) Establish internal audit process to verify all covered claims meet all Section I criteria A-D before submission. Claims submitted without complete documentation or meeting contraindications will be denied as not medically necessary. Next review date: June 2026.