Proposed CMS rules may exclude some patients from THA eligibility

LAS VEGAS — Proposed rules from the CMS pertaining to radiographic criteria needed to cover primary total hip arthroplasty may eliminate coverage for thousands of patients with osteoarthritis who may benefit from surgery, according to study findings presented here.

Data from a retrospective study of 249 patients with osteoarthritis (OA) who underwent total hip arthroplasty (THA) between January 2009 and December 2010 were presented by Yevgeniy Korshunov, MD, during the American Academy of Orthopaedic Surgeons Annual Meeting.

Patients with fractures, tumors or without adequate radiographic data were excluded. Average patient age was 56 years, and nine of the patients were female. Average follow-up was 25 months. Korshunov and colleagues graded all patient radiographs based on the proposed CMS criteria.

Eleven patients who underwent THA and did not meet the proposed Medicaid guidelines were identified. Of the patients who did not meet the new criteria, 82% had excellent outcomes, according to Korshunov. Additionally, a meaningful increase in Harris Hip Score was seen in most patients.

The rate of patients who underwent THA but did not meet the CMS criteria in the sample group was 4.4%, according to Korshunov, who said that if this rate is comparable among the total U.S. population of patients with OA who are willing to undergo THA, the proposed changes could translate to about 13,000 people who would not be eligible for coverage under Medicare.

“By applying such rigid criteria, we will miss patients who may benefit by surgery but will not meet criteria,” Korshunov concluded. – by Shirley Pulawski

Reference:

Korshunov Y, et al. Paper #586. Presented at: American Academy of Orthopaedic Surgeons Annual Meeting; March 24-28, 2015; Las Vegas.

Disclosure: The researchers report no relevant financial disclosures.