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Usually coveredPrior auth: Always required

Does Medicaid cover hip resurfacing?

Metal-on-metal hip resurfacing is covered by most major commercial insurers for appropriate candidates - typically younger, active male patients with good bone quality and end-stage hip arthritis. Coverage criteria often mirror total hip replacement. Some plans require documentation of why resurfacing is preferred over total hip replacement for that specific patient. FDA-cleared hip resurfacing implants (Birmingham Hip Resurfacing is the most common) are covered.

Quick summary

Coverage

Usually covered

Prior authorization

Always required

Typical patient cost

With commercial insurance: $1,500-$5,000. Comparable to total hip replacement cost-sharing. Without insurance, hospital charges often exceed $35,000.

Prior authorization for Medicaid

Medicaid covers orthopedic services deemed medically necessary, including office visits, imaging, and surgical procedures. Coverage specifics and provider availability vary by state. Some states require managed care plan enrollment, while others use fee-for-service models. Prior authorization is commonly required for elective orthopedic procedures.

Always verify your specific Medicaid plan before scheduling. Plans within the same insurer (Medicaid) can have different prior authorization rules, network requirements, and cost-sharing. Call the number on the back of your insurance card or log into your plan portal to confirm coverage for your specific plan.

How to confirm your coverage before scheduling

  1. 1Call Medicaid member services (number on back of your insurance card) and ask specifically if hip resurfacing is covered under your plan.
  2. 2Ask your orthopedic surgeon's office to verify benefits on your behalf - they do this routinely and can identify in-network requirements.
  3. 3Request the prior authorization criteria in writing if prior auth is required. Ask what documentation is needed from your surgeon.
  4. 4Confirm your deductible remaining for the year - your out-of-pocket cost depends on where you are in the deductible cycle.
  5. 5Get a pre-service cost estimate from the facility if you want a specific dollar figure before scheduling.

What to do if Medicaid denies coverage

Insurance denials for orthopedic procedures are common and frequently overturned on appeal. Follow these steps:

  1. 1Document why hip resurfacing is appropriate for this patient (age, activity level, bone quality)
  2. 2Confirm use of an FDA-cleared implant system
  3. 3Note that the indication (end-stage hip arthritis) is the same as total hip replacement
  4. 4Request peer-to-peer review if denied for being "investigational"

Common questions

Does insurance prefer total hip replacement over resurfacing?
Some plans require documentation of why resurfacing is clinically preferable for the specific patient, rather than the more standard total hip. A well-written letter of medical necessity from your surgeon - addressing bone quality, age, activity demands, and the specific advantages of resurfacing - is the key document for prior authorization.

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Medicaid coverage overview