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CurrentAetnaPolicy 0736

Femoro-Acetabular Surgery for Hip Impingement Syndrome

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Defines medical necessity, covered and experimental procedures, and applicable CPT/ICD-10 codes for femoro-acetabular surgery (open or arthroscopic) for hip impingement syndrome for Aetna members.

Policy Summary

PayerAetna

PolicyFemoro-Acetabular Surgery for Hip Impingement Syndrome

Policy CodePolicy 0736

Change TypeNo material change

Effective DateSep 21, 2007

Last ReviewNov 20, 2023

Next Review DateAug 8, 2024

Key ActionObtain and document imaging, clinical findings, symptom duration and at least 12 weeks of failed conservative therapy (including ≥6 weeks in-person physiotherapy) before seeking authorization for hip arthroscopy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5,085publications reviewed

47publications met criteria

>50°alpha angle threshold

≥40°center edge angle threshold

≥2 mmminimum joint space

12 wksconservative therapy duration

Coverage Criteria for Femoro‑acetabular Surgery (FAI)

inv-01: Medical necessity — FAI surgery — Aetna considers femoro-acetabular surgery, open or arthroscopic, medically necessary when ALL of the following are met:

Aetna considers femoro-acetabular surgery, open or arthroscopic, medically necessary when ALL of the following are met:

FAI surgical medical necessity: 1) Definite diagnosis of femoro-acetabular impingement (FAI) documented by appropriate imaging (X‑ray, MRI or CT) showing labral pathology (partial or full‑thickness tear or labral damage) plus one or more of: cam impingement (alpha angle > 50 degrees), pincer impingement (acetabular retroversion or coxa profunda; center‑edge angle ≥ 40 degrees), or pistol‑grip deformity; AND 2) Moderate to severe symptoms typical of FAI (hip/groin pain worsened by flexion activities that significantly limit activities) with duration of at least 6 months; AND 3) Positive impingement sign (pain on 90° hip flexion with adduction and internal rotation, or on extension with external rotation); AND 4) Failure of all available conservative treatments including activity modification, NSAIDs, intra‑articular local anesthetic injections, and physiotherapy for at least 12 weeks in the past year with at least 6 weeks of formal (in‑person) physiotherapy; AND 5) Member is ≥ 15 years of age or skeletally mature (epiphyseal closure); AND 6) Absence of advanced osteoarthritis on preoperative X‑ray (Tönnis grade ≥2) or severe cartilage injury (Outerbridge grade III–IV); AND 7) Absence of joint‑space narrowing on plain radiograph (joint space not < 2 mm anywhere along the sourcil); AND 8) No generalized joint laxity conditions associated with hypermobility (e.g., Marfan or Ehlers‑Danlos syndromes); AND 9) No osteogenesis imperfecta.all conditions required

Policy specifies radiographic thresholds and documentation requirements; see imaging documentation notes in policy.

Policy Summary

PayerAetna

PolicyFemoro-Acetabular Surgery for Hip Impingement Syndrome

Policy CodePolicy 0736

Change TypeNo material change

Effective DateSep 21, 2007

Last ReviewNov 20, 2023

Next Review DateAug 8, 2024

SourceLink

On This Page

inv-02: Medically necessary — labral tear repair — Hip arthroscopy to repair a labral tear is considered medically necessary when ANY of the following are met:

Hip arthroscopy to repair a labral tear is considered medically necessary when ANY of the following are met:

Labral repair indications: 1) Traumatic labral tears causing mechanical symptoms (unstable/traumatic tear in a reparable, good‑quality labrum); OR 2) When performed as an adjunct to femoro‑acetabular impingement (FAI) surgery.

Degenerative labral tears related to early osteoarthritis are not supported for routine repair (see policy for cautions).

inv-03: Experimental / Investigational — Aetna considers the following experimental/investigational for FAI treatment:

Aetna considers the following experimental/investigational for FAI treatment:

Experimental/Investigational procedures: Autologous osteochondral mosaicplasty combined with femoral neck osteochondroplasty; capsular plication; debridement or repair of the ligamentum teres when provided as an adjunct to FAI surgery; endoscopic tenotomy (or lengthening) for iliopsoas tendinopathy following total hip arthroplasty; hip arthroscopy to repair degenerative labral tears (eg, due to early osteoarthritis); hip arthroscopy to treat acetabular dysplasia without addressing dysplasia via osteotomy; labral reconstruction for treatment of FAI; anterior‑inferior iliac spine (AIIS) decompression; debridement of trochanteric bursitis; hip microfracture; lesser trochanteric resection; repair of partial gluteus medius tears (note: repair of complete gluteus medius tears is considered medically necessary).

These procedures are considered investigational as adjuncts to FAI surgery per policy.

inv-04: Literature-based indications — Commonly reported indications for arthroscopic FAI surgery in the literature include

Commonly reported indications for arthroscopic FAI surgery in the literature include

Common literature-based indications: Positive impingement sign AND symptoms/pain > 6 months AND a series of positive special tests; imaging evidence of cam or pincer morphology on radiographs, CT, or MRI/MR‑arthrography (loss of head‑neck offset, alpha angle > 50°, coxa profunda, acetabular retroversion).alpha angle > 50°

Derived from systematic reviews and guideline summaries.

inv-05: Selection criteria and outcome predictors — Surgical intervention (open or arthroscopic) for symptomatic FAI may be considered when patient selection criteria predict benefit; selection factors and predictors summarized.

Surgical intervention (open or arthroscopic) for symptomatic FAI may be considered when patient selection criteria predict benefit; selection factors and predictors summarized.

Candidate selection: Symptomatic FAI with documented anatomic lesion (cam, pincer, or combined) clinically and radiographically AND absence of advanced radiographic joint‑space narrowing or severe osteoarthritis (eg, Tönnis grade >1 or joint space ≤ 2 mm). Preserved joint space (>2 mm) predicts better survivorship and functional outcomes.joint space > 2 mm

Multiple cohort studies report poorer outcomes and higher conversion to THA when joint‑space ≤ 2 mm.

inv-06: Evidence-informed surgical indications and technique considerations — Evidence-informed considerations for offering hip arthroscopic surgery and specific techniques

Evidence-informed considerations for offering hip arthroscopic surgery and specific techniques

Imaging and joint‑space assessment: Document imaging‑defined FAI with measured joint space and radiographic parameters; preserved joint space (>2 mm) associated with better 5‑year outcomes.joint space > 2 mm

Skendzel and others report improved survivorship with preserved joint space.

Capsular management: Complete capsular repair (full closure) may provide superior sport‑specific outcomes and fewer revisions compared with partial repair based on cohort data.

Frank et al cohort showed better HOS‑SS and fewer revisions with complete repair.

Conservative therapy evidence: Randomized trial evidence shows superiority of arthroscopic surgery versus non‑operative care at 12 months but not clearly at 24 months; document prior conservative management and response before surgery.

Systematic reviews of RCTs summarized in policy.

Femoral version assessment: Assess femoral version (CT or MRI) as part of preoperative workup; reportable ranges include retroversion <5°, normal 5°–20°, anteversion >20°.FV thresholds per policy

Measurement heterogeneity exists; interpretation should be documented.

Labral reconstruction considerations: Consider labral reconstruction for irreparable or deficient labra in young, active patients with minimal arthritis; short‑term data show functional improvement though failure/conversion rates vary.absence of significant arthritis

Evidence from systematic reviews and case series supports selective use.

inv-07: Indications and expected outcomes — Clinical indications and observed outcome patterns described in the literature

Clinical indications and observed outcome patterns described in the literature:

Primary indication for reconstruction: Irreparable or deficient acetabular labrum determined intra‑operatively is the most common indication for labral reconstruction.

Multiple systematic reviews and series cite intra‑operative assessment as primary indication.

Typical candidate profile: Young, active patients with minimal or no arthritis (Tönnis 0–1) are typical candidates for reconstructive procedures.Tonnis 0–1

Cohort and case‑series data support this selection.

Expected outcomes: Short‑ and mid‑term improvements in patient‑reported outcomes (eg, mHHS, NAHS, HOS‑SSS) and pain reduction are commonly reported; pooled mHHS improvement ~29 points in some series.

Follow‑up intervals commonly ≥1–2 years.

Risks and failures: Conversion to total hip arthroplasty and revision rates vary across studies (conversion ranges reported from 0% up to ~27% in some cohorts); outcomes depend on patient selection and degree of arthritis.

Ranges reported across systematic reviews and cohort studies.

Graft and technique: No consistent superiority of graft types; choice influenced by surgeon experience, graft availability, and patient factors.

Systematic reviews report heterogeneous techniques and grafts with overall improvements.

inv-08: Indications and evidence summary — Clinical findings and reported indications from the evidence base

Clinical findings and reported indications from the evidence base

Indications and evidence summary: Labral reconstruction is considered for irreparable or deficient labral tears, diminutive/hypoplastic labra, or when labral tissue quality/size is inadequate for repair; may be performed in primary and revision settings; capsular plication may be considered to address instability or borderline dysplasia.

Evidence consists mainly of cohort and case‑series studies reporting improved PROs.

inv-09: Coverage-related clinical indications (evidence summary) — Procedures may be considered when clinical and imaging findings align with symptomatic mechanical impingement or instability and conservative therapy has failed

Procedures may be considered when clinical and imaging findings align with symptomatic mechanical impingement or instability and conservative therapy has failed

Capsular plication for instability: Arthroscopic capsular plication may be indicated for patients with atraumatic micro‑instability, capsular laxity (eg, easily distractible hip), or Ehlers‑Danlos‑associated instability presenting with pain and giving‑way, and who have failed conservative care; cohort series report improvements in PROs and stability after plication.

Evidence level III–IV; document exam findings and failed conservative care.

AIIS (sub‑spinal) decompression: Consider arthroscopic AIIS decompression for symptomatic sub‑spinal impingement due to low/extended AIIS causing decreased ROM and groin pain when imaging or intra‑operative findings confirm impingement and conservative measures have failed; small series report improved PROs when added to FAI correction.

Pre‑operative radiographs may miss low AIIS; consider dedicated imaging or intra‑operative assessment.

Labral repair for traumatic tears: Hip arthroscopy for traumatic labral tears causing mechanical symptoms may be indicated in patients with good‑quality labrum and preserved joint space; degenerative labral tears as sole indication are cautioned against due to association with early osteoarthritis and uncertain benefit.

Document traumatic etiology, mechanical symptoms, and preserved joint space.

Arthroscopy in borderline dysplasia: Selected patients with borderline acetabular dysplasia (LCEA 18°–25°) undergoing arthroscopic treatment with labral refixation and complete capsular closure have shown favorable short‑term outcomes in cohort studies; careful selection is required.LCEA 18°–25°

Evidence level III; ensure capsular management documented.

Computer‑assisted techniques: CT‑based preoperative planning and intra‑operative navigation can aid precise osteochondroplasty for cam/pincer lesions but require documentation of planning and registration; consider radiation exposure and technical limitations.

Technical adjunct with limited evidence; document use and results.

inv-10: Clinical scenarios with reported benefit — Clinical scenarios in which arthroscopic procedures showed benefit in the cited literature

Clinical scenarios in which arthroscopic procedures showed benefit in the cited literature

FAI in borderline/mild dysplasia: Patients with borderline acetabular dysplasia (LCEA 18°–25°) treated with arthroscopic FAI correction (cam decompression, labral refixation/repair) and complete capsular closure have demonstrated significant short‑ to mid‑term PRO improvement with revision rates comparable to non‑dysplastic cohorts in cohort studies.LCEA 18°–25°

Evidence level III–IV; longer follow‑up needed.

Subtypes with better outcomes: Specific morphologic clusters (eg, stable antero‑lateral deficiency, stable lateral deficiency) have shown consistently better iHOT‑12 and VAS improvements compared with unstable or retroversion clusters in subgroup analyses.

Cluster classification per cohort analyses (Zimmerer et al).

Endoscopic/arthroscopic iliopsoas tenotomy after THA: Patients with iliopsoas tendinopathy after total hip arthroplasty who have failed ≥6 months of conservative treatment, have exclusion of other complications, and have diagnostic confirmation (eg, positive diagnostic injection) experienced substantial pain relief and functional improvement after endoscopic/arthroscopic tenotomy in multiple series (reported pain alleviation ~92–93% and significant PRO gains).failure of conservative care (~6 months) and diagnostic confirmation

Some series report no clear association between cup overhang/anteversion and outcomes; diagnostic infiltration recommended.

inv-11: Indications for endoscopic iliopsoas tenotomy after THA — Covered when ALL of the following are met (evidence and practice statements from the document):

Covered when ALL of the following are met (evidence and practice statements from the document):

Endoscopic iliopsoas tenotomy after THA criteria: 1) Groin pain during active hip‑flexion attributed to iliopsoas tendinopathy following total hip arthroplasty; AND 2) Other complications (eg, infection, metallosis, component loosening) excluded; AND 3) Failure of adequate conservative treatment for at least 6 months; AND 4) Pre‑tenotomy imaging performed (radiographs ± CT) to assess cup anteversion, inclination and axial/sagittal overhang; AND 5) Diagnostic infiltration considered/used to confirm iliopsoas source of pain.

Studies report high rates of pain alleviation; consider acetabular revision if cup protrusion/overhang > ~8 mm per review recommendations.

Aetna considers surgery for femoro‑acetabular impingement (FAI) to be experimental and investigational for indications not specifically listed as medically necessary. The policy explicitly identifies several procedures as experimental/investigational when used for FAI or as adjuncts, including labral reconstruction, capsular plication, autologous osteochondral mosaicplasty combined with femoral neck osteochondroplasty, debridement or repair of the ligamentum teres as an adjunct, endoscopic tenotomy/lengthening for iliopsoas tendinopathy after total hip arthroplasty, and arthroscopic treatment of acetabular dysplasia when the dysplasia is not addressed with osteotomy. Additional procedures listed as investigational when provided as adjuncts include anterior‑inferior iliac spine (AIIS) decompression, debridement of trochanteric bursitis, hip microfracture, lesser trochanteric resection, and repair of partial gluteus medius tears.

The evidence and study inclusion criteria indicate that patients with advanced degenerative changes (for example, higher Tönnis grades, diminished lateral sourcil height, or severe chondral injury) were frequently excluded from outcome studies and show inferior results after FAI surgery. Cohort data (Larson et al.) report substantially worse functional improvements and a markedly higher failure rate when preoperative radiographs demonstrate significant joint degeneration, and multiple reviews emphasize that advanced radiographic osteoarthritis predicts poorer surgical outcomes and earlier conversion to total hip arthroplasty.

Multiple studies and systematic reviews report that patients with advanced pre‑existing osteoarthritis or significant radiographic joint‑space narrowing experience worse outcomes and higher rates of conversion to total hip arthroplasty after arthroscopic FAI procedures. Reviews of the literature (including analyses with minimum 2‑year follow‑up) document conversion rates up to the mid‑teens and indicate that long‑term benefit is unproven in hips with substantial degenerative change.

The policy and supporting reviews identify significant arthritis or advanced degenerative changes as a relative contraindication to labral reconstruction. The primary documented indication for labral reconstruction in the literature is an irreparable or deficient labrum in younger, active patients with minimal arthritis; patients with marked osteoarthritis were generally excluded from reconstruction series and outcomes are less favorable when significant cartilage pathology exists.

Many published series excluded patients with substantial degenerative joint disease or prior complex hip conditions. Labral reconstruction cohorts and other outcome studies typically selected patients without advanced osteoarthritis (for example, Tönnis grade greater than study thresholds) or prior hip procedures, meaning that the reported benefits do not apply to populations with significant pre‑existing hip disease.

Within the cited excerpts there are no additional explicit exclusions beyond those already described for advanced arthritis, significant joint‑space narrowing, generalized connective‑tissue hypermobility disorders, and osteogenesis imperfecta.

Degenerative labral tears—those occurring in the setting of early osteoarthritis—are typically a marker of joint degeneration rather than an isolated mechanical lesion. The evidence does not support routine arthroscopic refixation of degenerative labral tears when repair is the sole intervention; published reviews note limited data that routine repair of degenerative labra reliably improves outcomes and caution that degenerative tissue may be associated with persistent symptoms.

Arthroscopic treatment of severely dysplastic hips has historically been associated with poor outcomes and the risk of iatrogenic instability. Studies and systematic reviews cite unfavorable results in hips with marked dysplasia (for example, LCEA < 18°), and arthroscopy alone without addressing the underlying acetabular deficiency is generally not favored in these cases.

In the evaluation of iliopsoas tendinopathy after total hip arthroplasty, diagnostic infiltration is important and the literature notes that when acetabular cup protrusion (overhang) exceeds approximately 8 mm, consideration should be given to acetabular revision rather than isolated iliopsoas tenotomy.

The policy states that arthroscopic debridement of the hip as an isolated procedure is considered experimental/investigational because its efficacy has not been proven; accordingly diagnostic hip arthroscopy (CPT 29860) is generally not covered as a sole procedure unless radiologically proven pathology meeting policy criteria is found intra‑operatively.

Systematic reviews and meta‑analyses report insufficient high‑quality comparative evidence to demonstrate a sustained superiority of surgical over conservative care across all patient populations. For populations without clear selection criteria (for example, those with advanced degenerative change or without documented mechanical symptoms), the available evidence is inadequate to establish that surgery yields better long‑term outcomes than nonoperative management, and surgical candidacy should therefore be selective.

A recent meta‑analysis and systematic reviews found that arthroscopic surgical treatment showed superiority over conservative care for some hip‑specific outcomes at 12 months but not clearly at 24 months, and overall the evidence was graded moderate to low quality. Consequently, surgical treatment is not uniformly superior to conservative treatment in the short‑ to medium‑term, supporting selective surgical candidacy and requirement for documented prior conservative care.

The provided excerpts summarize evidence and clinical considerations but do not state payer‑specific administrative determinations using the phrase 'not medically necessary' for particular services beyond the investigational and excluded procedures already listed.

Similarly, the text excerpts do not include standalone insurer 'not medically necessary' statements beyond descriptions of insufficient evidence for certain indications; the document focuses on evidence summaries, exclusions, and investigational procedures rather than repeating a distinct 'not medically necessary' sentence in these sections.

Routine arthroscopic repair of degenerative labral tears to treat degenerative hip symptoms—without demonstrable mechanical instability or a clearly reparable lesion—is of uncertain benefit. Reviews and expert commentaries caution that degenerative labral tissue often indicates early osteoarthritis and that repair alone may not address the underlying joint disease.

The document does not set out explicit administrative 'not‑medically‑necessary' rulings for every scenario in these excerpts; it does, however, note historically poor outcomes for severe dysplasia treated arthroscopically and highlights the low level of evidence supporting some procedures, which are potential bases for non‑coverage in practice.

Several procedures and indications cited in the policy and supporting reviews are supported primarily by low‑level evidence (grade‑3 or grade‑4 case series and small cohorts). The authors of systematic reviews note low statistical power and limited validity of conclusions for many of these indications, and recommend cautious interpretation of reported benefits pending higher‑quality comparative studies.

Coding and Measurement Thresholds

Covered CPT Codes (if selection criteria met)CPTCovered

29914	Arthroscopy, hip, surgical; with femoroplasty (ie, treatment of cam lesion).
29915	Arthroscopy, hip, surgical; with acetabuloplasty (ie, treatment of pincer lesion).
29916	Arthroscopy, hip, surgical; with labral repair.

CPT Codes with coverage limitations or not separately reimbursableCPT

29860	Arthroscopy, hip, diagnostic with or without synovial biopsy (separate procedure).
29862	Arthroscopy, hip, surgical; with debridement/shaving of articular cartilage (chondroplasty), abrasion arthroplasty, and/or resection of labrum.

Other CPT codes related to CPB (covered if criteria met)CPTCovered

29861	Arthroscopy, hip, surgical; with removal of loose body or foreign body.
29863	Arthroscopy, hip, surgical; with synovectomy.

ICD-10 Codes covered if selection criteria are metICD-10Covered

M24.151 - M24.159	Other articular cartilage disorders, hip [hip impingement syndrome].
M25.551 - M25.559	Pain in hip [hip impingement syndrome].
M24.051 - M24.059	Loose body in hip.
S73.001A - S73.199S	Dislocation and sprain of joint and ligament of hip [hip impingement syndrome].

ICD-10 Codes not covered for indications listed in the CPBICD-10Not Covered

M16.0 - M16.9	Osteoarthritis of hip [advanced osteoarthritis].
Q78.0	Osteogenesis imperfecta.
Q79.6	Ehlers-Danlos syndrome.
Q87.40 - Q87.43	Marfan's syndrome.

Coding not specifiedmixed

No codes listed

Outcome measures reportedmixed

mHHS	Modified Harris Hip Score (patient-reported outcome measure)
NAHS	Nonarthritic Hip Score
HOS-SSS	Hip Outcome Score - Sport Specific Subscale
HOS-ADL	Hip Outcome Score - Activities of Daily Living
iHOT	International Hip Outcome Tool
VAS	Visual Analog Scale for pain

Codes referencedmixed

No codes listed

inv-37: Alpha angle — measurement threshold reported (> 50 degrees)

Alpha angle thresholdAlpha angle greater than 50 degrees indicates cam impingement (radiographic threshold >50°)

Measurement purposeAlpha angle measures femoral head–neck contour to quantify cam deformity

Clinical contextUsed with radiographs, MRI or CT to support diagnosis of cam-type FAI

inv-38: Center edge angle — measurement threshold (>= 40 degrees)

Center edge angle thresholdCenter edge angle greater than or equal to 40 degrees predicts pincer impingement (radiographic threshold ≥40°)

DefinitionAngle formed by a vertical line and a line from the femoral head center to the lateral acetabular edge

Normal rangeNormal center edge angle varies between approximately 25° and 39°

inv-39: Minimum joint space — radiographic threshold (>= 2 mm anywhere along the sourcil)

Minimum joint space for surgeryJoint space not less than 2 mm anywhere along the sourcil (minimum ≥2 mm)

Imaging modalityMeasured on plain pelvis radiograph (sourcil measurement)

Exclusion implicationPresence of joint space <2 mm or advanced OA argues against arthroscopic FAI surgery

inv-40: Alpha angle (repeat source) — > 50°

Alpha angle repeat thresholdAlpha angle > 50° cited as commonly reported indication for arthroscopic FAI management

Role in literatureAlpha angle >50° frequently appears in study inclusion criteria and imaging reports

Associated findingsAlpha angle elevation often accompanied by loss of head–neck offset and cam lesion on imaging

inv-41: Joint space narrowing associated with better outcomes — >= 2 mm

Joint space associated with better outcomesRadiographic joint space ≥ 2 mm associated with improved survivorship and functional outcomes after hip arthroscopy

Study evidenceSkendzel et al and related cohorts show preserved joint space (>2 mm) predicts better 5‑year outcomes

Clinical applicationDocument pre-operative joint-space measurement when assessing candidacy

inv-42: Radiographic joint space — > 2 mm versus <= 2 mm (outcome predictor)

Radiographic joint space as outcome predictorStudies differentiate >2 mm (preserved) versus ≤2 mm (limited) joint space as predictors of survivorship and outcomes

Survivorship dataPatients >2 mm joint space had higher survivorship and better PRO improvements compared with ≤2 mm

Decision implicationLimited joint space (≤2 mm) should prompt caution and discussion of higher THA conversion risk

inv-43: Radiographic joint space threshold — <= 2 mm (risk for poor outcome / THA conversion)

Risk threshold for poor outcome / THA conversionRadiographic joint space ≤ 2 mm associated with poorer outcomes and higher conversion to total hip arthroplasty

Evidence sourceSkendzel et al and Phillipon et al report earlier conversion and lower survivorship with ≤2 mm joint space

Clinical actionConsider nonoperative management or alternative procedures in patients with joint space ≤2 mm

inv-44: Femoral version ranges — Retroversion < 5°; Normal 5°–20°; Anteversion > 20°

Femoral version categoriesRetroversion: less than 5°; Normal: 5°–20°; Anteversion: greater than 20°

Assessment methodsFemoral version measured by CT or MRI in studies assessing impact on arthroscopy outcomes

Outcome relevanceSystematic review found no consistent difference in outcomes by abnormal femoral version in included studies

inv-46: PASS and MCID thresholds reported — mHHS PASS >74; mHHS MCID >8; HOS-SSS PASS >75; HOS-SSS MCID >6

mHHS PASS/MCIDmHHS PASS >74; mHHS MCID >8 (used to assess clinical success)

HOS-SSS PASS/MCIDHOS-SSS PASS >75; HOS-SSS MCID >6

ApplicationPASS and MCID rates reported in labral reconstruction and athlete cohorts to gauge meaningful improvement

inv-46: Lateral center-edge angle (LCEA) — Borderline dysplasia: 18°–25°; non-dysplastic: 25°–40°

Lateral center-edge angle (LCEA) — borderline dysplasiaBorderline dysplasia defined as LCEA approximately 18°–25°

Non-dysplastic rangeNon-dysplastic acetabular coverage defined as LCEA approximately 25°–40°

Clinical implicationArthroscopy may be considered in borderline dysplasia with careful selection and capsular management

inv-47: Acetabular component prominence (overhang) — reported examples and thresholds referenced in studies

Acetabular component prominence examplesMean anterior prominence reported 7.25 mm (range 3–12 mm); success noted when prominence <10 mm in one series

CT overhang measuresAxial and sagittal overhang means reported ~3–7 mm depending on measurement method in study cohorts

Clinical implicationDiagnostic injections recommended and consider acetabular revision if cup protrusion >8 mm instead of isolated tenotomy

Provider Actions, Prior Authorization & Documentation

Prior Authorization

Prior Authorization Required When Criteria Apply

Prior authorization required when selection criteria apply. Certain hip arthroscopy CPT codes (e.g., 29914, 29915, 29916) are covered only if the policy’s documented medical-necessity selection criteria are met (see policy medical necessity section). Diagnostic-only arthroscopy (CPT 29860) is generally not covered unless radiologically proven pathology is absent at time of surgery and billing for 29860 is appropriate per policy notes. Providers should obtain prior authorization when local plan procedures require it and submit required supporting clinical documentation.

Covered CPT when criteria met: 29914, 29915, 29916
Diagnostic arthroscopy (29860) generally not covered; may be billed if radiologic pathology not found at surgery

Documentation Required

Clinical Justification and Registry Reporting

Clinical justification must be documented for surgical decisions and providers are encouraged to report cases to registries when available. Documentation should include imaging findings (X‑ray, MRI, CT), symptom duration, failed conservative therapy, and rationale for surgery (e.g., traumatic labral tear, adjunct to FAI correction). Registry reporting (e.g., national hip registries) supports long‑term outcomes and patient-selection data.

Document imaging: alpha angle, cam/pincer lesions, coxa profunda, labral tear description
Document symptom duration and positive impingement sign
Report to registries when feasible per guidance

Prior Authorization

Prior Authorization Should Assess Joint-Space/Arthritis Status

Prior authorization review should explicitly assess pre-operative joint-space and radiographic evidence of arthritis. Evidence shows advanced joint‑space narrowing and other degenerative changes predict worse outcomes and higher rates of conversion to total hip arthroplasty; therefore document joint-space measurements and Tönnis grade.

Radiographic joint-space measurement (must be ≥ 2 mm per policy)
Document Tönnis grade and any Outerbridge cartilage grading if available
Note: limited joint space (≤ 2 mm) is associated with higher failure and conversion to THA

Prior Authorization

Prior Authorization: Document Prior Conservative Care and Indication

Prior authorization submissions should include documentation of prior conservative care and clear indication for surgery. The policy requires failure of available conservative treatments (activity modification, NSAIDs, intra‑articular injections, and formal physiotherapy) for at least 12 weeks in the past year with at least 6 weeks being in-person formal physiotherapy, unless other criteria (e.g., traumatic labral tear) apply.

Document conservative therapy type, duration and dates (activity modification, NSAIDs, injections, physical therapy)
If traumatic labral tear or other exception, include justification

Note

Prior Authorization Not Specified in Excerpt

No specific prior authorization or step-therapy coding requirement is specified in parts of the source excerpts. Providers should follow the payer’s standard prior authorization processes and local plan requirements; if no prior authorization requirement exists, document clinical criteria in the medical record.

When PA is not specified in excerpt, rely on plan’s administrative rules
Maintain thorough clinical documentation even when no PA is mandated

Prior Authorization

AIIS Decompression — Prior Authorization Considerations

Arthroscopic AIIS (sub‑spinal) decompression may be appropriate for symptomatic low AIIS causing impingement; prior authorization documentation should include imaging (AIIS type on radiographs/CT), description of symptoms, and intra-operative findings when applicable to justify the procedure.

Document AIIS morphology (radiograph/CT) and intra-operative correlation
Provide clinical symptoms and failure of conservative care where applicable

Note

Prior Authorization Not Specified in These Excerpts

Some reviewed excerpts do not specify prior authorization requirements for specific procedures. Providers should check payer-specific authorization rules and submit required clinical documentation when requesting authorization.

If PA rules absent in excerpt, follow payer’s current PA portal/process
Include imaging and diagnostic injection reports if relevant

Note

Prior Authorization Guidance

Prior authorization guidance: Clinical Policy Bulletins provide guidance to assist plan benefit administration but do not replace plan terms. Providers remain responsible for medical decision‑making; verify member benefits and authorization requirements before performing procedures.

Clinical Policy Bulletins assist with benefit administration but are not guarantees of coverage
Providers must verify eligibility and prior authorization requirements with the payer

Note

Selection and Evidence Limitations

Selection and evidence limitations: available evidence shows short- and mid-term symptomatic improvement after arthroscopic FAI surgery but has limitations (observational designs, heterogeneity, limited long‑term data). Patient selection criteria and registry reporting are important to improve outcome understanding.

Evidence largely observational; long-term benefits (e.g., prevention of osteoarthritis) not established
Encourage careful patient selection and registry participation

Denial Risk

Joint-Space Narrowing Predicts Poor Outcomes

Joint-space narrowing predicts poor outcomes. Studies report patients with advanced pre-operative joint-space narrowing have inferior improvements and higher failure and conversion-to-THA rates; document joint-space measurements in authorization and operative planning.

Limited joint space (≤ 2 mm) associated with higher conversion to THA
Report mean survival estimates and conversion statistics when available

Denial Risk

Risk Factor for Earlier THA

Limited joint space is a risk factor for earlier total hip arthroplasty (THA). Prior authorization reviewers should consider documented joint-space width and counsel regarding increased likelihood of earlier THA when joint space is ≤ 2 mm.

Include counseling notes in plan of care when joint-space is limited
Document patient understanding of increased THA risk

Note

Not Present in This Document Segment: No Additional Administrative Rules

Not present in this document segment: no additional administrative authorization rules beyond those summarized. Providers should follow the payer’s standard prior authorization process and document clinical criteria in the record.

When administrative content is absent, rely on payer portals and standard PA workflows

Note

Not Applicable in This Excerpt — No Explicit Authorization Rules Stated

Not applicable in this excerpt — no explicit authorization or coverage rules are stated for certain described techniques; verify coverage and prior authorization with the payer for procedures such as novel techniques or adjunctive procedures.

Novel or experimental procedures (see policy’s experimental list) may not be covered
Validate coverage for computer-assisted techniques and labral reconstruction per policy

Prior Authorization

Diagnostic Tests with Infiltration Should Precede Iliopsoas Release

Diagnostic tests with infiltration (e.g., image-guided anesthetic/injection) should be performed prior to iliopsoas release to confirm pain generator and reduce risk of treatment failure. Document diagnostic injection results and imaging measurements (cup prominence/overhang) when submitting for authorization.

Document diagnostic injection response (e.g., pain relief)
Pre-tenotomy imaging: radiographs and CT measurements of cup anteversion, inclination, and overhang
Cup protrusion > 8 mm may indicate need for cup revision rather than isolated tenotomy

Note

Clinical Policy Bulletins Are Developed to Assist With Benefit Administration

Clinical Policy Bulletins are developed to assist in administering plan benefits and do not constitute a guarantee of coverage. Absence of coverage elsewhere does not imply coverage; providers must verify member-specific benefits and obtain required authorizations.

CPBs guide benefit administration but are not coverage guarantees
Verify member benefits and PA requirements through payer systems

Documentation Required

Required Clinical Documentation Elements (Examples from Literature)

Required clinical documentation elements (examples from the literature) that support prior authorization and medical necessity reviews include pre-operative imaging reports (radiographs, MRI, CT) with lesion characterization (alpha angle, cam/pincer, center-edge angle), symptom duration, positive impingement sign, prior conservative therapy details, outcome scores when available, and exclusion of advanced osteoarthritis (Tönnis grade ≤ 1 and joint-space ≥ 2 mm).

Imaging: AP and lateral radiographs, MRI/arthrogram, CT if used; report alpha angle and LCEA
Clinical: symptom duration (>6 months typical), positive impingement exam, failed conservative therapy dates
Exclude advanced OA: Tönnis grade and joint-space measurements

Note

Not Present in This Document Segment: Clinical Checklists

Not present in this document segment: clinician-level administrative checklists or templates for PA — providers should include the clinical elements listed above when seeking authorization.

Include outcome scores (mHHS, HOS) and radiographic lesion descriptions when possible
Attach official imaging reports and any addenda if surgeon disagrees with interpretation

Documentation Required

Outcome and Follow-Up Documentation

Outcome and follow-up documentation: studies report minimum follow-up intervals (e.g., ≥1 year, 2‑year, 5‑year) and commonly used PRO measures (mHHS, HOS, WOMAC, SF‑12, VAS). Where available, include pre- and post-operative PROs and follow-up duration in authorization and post-procedure records.

Report PROs such as mHHS, HOS-ADL, HOS-SS, WOMAC, SF‑12, VAS
Provide minimum follow-up duration and any conversions to THA

Documentation Required

Computer-Assisted Surgery Documentation

Computer-assisted hip arthroscopic surgery: when using CT‑based pre-operative planning or intra-operative navigation, include documentation of pre-operative CT planning data, navigation registration details, and validation of the navigation accuracy as part of the submission.

Provide CT-based planning reports and intra-operative navigation registration/validation notes
Document rationale for use and consideration of radiation exposure

Documentation Required

Imaging and Diagnostic Workup Described in Studies

Imaging and diagnostic workup described in studies: many studies require true lateral radiographs, CT measurements, MRI (including MR arthrography) and diagnostic injections. Prior authorization should include official imaging reports and, if the operating surgeon disagrees with an interpretation, a documented discussion and addendum per policy note.

True lateral radiograph and AP pelvis radiograph measurements
MRI/arthrogram or CT as indicated; include official reports and any surgeon addenda
Diagnostic injection results when used to localize pain source

Prior Authorization

Pre-Tenotomy Imaging and Diagnostic Requirements

Pre‑tenotomy imaging and diagnostic steps for iliopsoas procedures: obtain radiographs and CT where available to measure cup anteversion, inclination, and axial/sagittal overhang. Diagnostic image‑guided injections are recommended to confirm the iliopsoas tendon as the pain generator before endoscopic tenotomy.

Document pre‑tenotomy radiograph and CT measurements
Include diagnostic injection response and duration of failed conservative care (commonly no relief after ≥ 6 months)

Note

The Policy and Clinical Policy Bulletins

The policy and Clinical Policy Bulletins provide guidance for administering plan benefits but do not replace plan terms. Providers are responsible for confirming member eligibility, benefit limits, and obtaining any required prior authorizations through payer systems.

CPBs are advisory for administration; verify member-specific coverage
Obtain PA via payer portals when required and include complete clinical documentation

Documentation Required

Typical Preoperative Indications

Typical preoperative indications (from literature) include a positive impingement sign, symptoms >6 months, positive special tests, and imaging demonstrating cam/pincer lesions. Include these findings in prior authorization submissions to support medical necessity.

Positive impingement test (FADIR) documented
Imaging evidence: cam (alpha angle >50°), pincer (LCEA ≥40°), pistol‑grip deformity

Step Therapy

No Step Therapy or Conservative-Treatment Sequencing Specified in Excerpt

No specific step‑therapy or conservative‑treatment sequencing rules are specified in some excerpts; however, the policy requires documented failure of conservative therapy as described. Follow plan-specific step‑therapy requirements if present.

Policy requires ≥12 weeks of conservative care in past year with ≥6 weeks formal physiotherapy
If plan-level step therapy exists, follow payer workflow

Note

Clinical Sequencing (Informational)

Clinical sequencing (informational): labral reconstruction is generally considered after debridement and repair fail or when labrum is irreparable; this is informational and not a formal prior authorization step, though documentation should explain why reconstruction versus repair is chosen.

Document intra‑operative findings supporting irreparable labrum if reconstruction proposed
Explain prior attempts (repair/debridement) if reconstruction is revision surgery

Step Therapy

Conservative Therapy First

Conservative therapy first: conservative management is recommended prior to elective arthroscopic procedures except in specific circumstances (e.g., traumatic labral tear). Document conservative care attempts and response in the authorization packet.

Record dates and types of conservative treatments and objective response
Exceptions: traumatic labral tears causing mechanical symptoms may be an indication for earlier surgery

Step Therapy

Conservative Therapy Before Tenotomy

Conservative therapy before tenotomy: for iliopsoas impingement after THA, non‑operative management is first‑line; endoscopic tenotomy is considered when conservative care fails. Studies often required no pain relief after 6 months of conservative treatment before tenotomy.

Require documentation of ≥6 months of conservative care with lack of meaningful relief for tenotomy consideration
Include diagnostic injection and imaging prior to tenotomy

Background and Condition Description

Femoro‑acetabular impingement (FAI) is a condition in which abnormal contact between the femoral head‑neck junction and the acetabular rim causes hip or groin pain in young and middle‑aged adults; three morphologies are described—cam, pincer, or combined—and characteristic imaging findings include an elevated alpha angle (>50°) for cam lesions and an increased center‑edge/ LCEA (typically ≥40° for pincer) for acetabular overcoverage. FAI can lead to labral and cartilage damage and may progress to osteoarthritis if unaddressed.

Definitions and Measurement Concepts

inv-89: Alpha angle — measurement of femoral head–neck contour; >50° indicates cam impingement

Alpha angle — definitionMeasurement of femoral head–neck contour used to quantify cam impingement; an alpha angle >50° indicates cam impingement

Imaging modalitiesAlpha angle measured on radiographs, MRI or CT and used in clinical decision-making for cam-type FAI

Clinical relevanceElevated alpha angle correlates with cam lesion and cartilage injury antero-superiorly

inv-90: Center edge angle — angle used to quantify acetabular overcoverage; values ≥40° predict pincer impingement

Center edge angle — definitionAngle used to quantify acetabular coverage; center edge angle ≥40° predicts pincer impingement

Normal rangeNormal center edge angle approximately 25°–39°

Measurement useMeasured on AP radiographs to assess acetabular overcoverage (pincer)

inv-91: Iliopsoas impingement / tenotomy — definitions and basic procedural description

Iliopsoas impingement — definitionInflammation/tightness of the iliopsoas tendon causing snapping and labral irritation

Tenotomy — procedural noteTenotomy entails partial or total release/lengthening of the iliopsoas tendon to relieve tension, performed in native hips or after THA

Clinical featuresPresents with groin pain during hip flexion; diagnostic injection and imaging used to confirm diagnosis

inv-92: Peri-acetabular osteotomy — definition and brief description

Peri-acetabular osteotomy — definitionSurgical reorientation of the acetabulum via pelvic bone cuts and fixation (3–6 screws) to improve acetabular coverage

PurposeMay be combined with joint debridement from same incision to improve hip mechanics

IndicationUsed to correct acetabular dysplasia or coverage abnormalities contributing to FAI

inv-93: Cam, pincer, combined lesions — definition of lesion types

Lesion types — cam/pincer/combinedCam: femoral head–neck asphericity; Pincer: acetabular overcoverage; Combined: both lesions present

Clinical impactLesion type guides surgical planning (femoroplasty for cam, acetabuloplasty for pincer, or combined procedures)

Imaging correlationAlpha angle and center edge angle commonly used to characterize cam and pincer lesions respectively

inv-94: Preserved vs limited joint space — preserved defined as >2 mm; limited defined as ≤2 mm

Preserved vs limited joint space — definitionPreserved joint space defined as >2 mm; limited joint space defined as ≤2 mm

Prognostic notePreserved joint space predicts better survivorship and functional outcomes after hip arthroscopy

Measurement siteJoint space assessed along the sourcil on plain radiograph

inv-95: Limited joint space — Radiographic joint space ≤ 2 mm associated with poorer outcomes and higher conversion to THA

Limited joint space — outcome associationRadiographic joint space ≤2 mm associated with poorer outcomes and higher conversion to total hip arthroplasty after hip arthroscopy

Study evidenceSkendzel et al and other cohorts demonstrated earlier THA conversion and lower PROs in ≤2 mm group

Clinical implicationDocument joint-space measurement; limited space may contraindicate arthroscopic corrective procedures

inv-96: Complete capsular repair (CR) — definition and reported outcome context

Complete capsular repair — definitionFull closure of capsulotomy incisions during hip arthroscopy (CR) to restore capsule integrity

Reported outcome contextCohort data suggest CR yields superior sport-specific outcomes and fewer revisions compared with partial repair

DocumentationCapsular management should be recorded in operative notes for outcome assessment

inv-97: Labral reconstruction — definition and graft options summarized

Labral reconstruction — definitionSurgical reconstruction of an insufficient or irreparable acetabular labrum using graft tissue (e.g., iliotibial band autograft or allograft)

Graft optionsReported grafts include ITB autograft, gracilis tendon, fascia lata and other allografts

Primary indicationMost commonly indicated for irreparable labrum in young active patients with minimal arthritis

inv-98: Irreparable labrum — definition (primary indication for reconstruction)

Irreparable labrum — definitionLabral tissue judged not amenable to repair intra-operatively (primary indication for reconstruction)

AssessmentIrreparability commonly determined at surgery based on tissue quality and size

Associated indicationOften seen in young patients after prior excision or with hypotrophic/dysfunctional labrum

inv-99: Survivorship / Failure — outcome concepts including conversion to THA

Survivorship / Failure — conceptsOutcomes include graft survivorship, revisions, and conversion to total hip arthroplasty (THA) as measures of failure

Reported rangesConversion to THA and revision rates vary across studies (e.g., 0%–13.2% conversion in some series)

Follow-up importanceMinimum 2‑year and longer follow-up often used to report survivorship and failure metrics

inv-100: Labral width/height/length — measurement definitions

Labral width/height/length — definitionsWidth: distance from chondro-labral junction to tip; Height: distance from joint surface to peri-labral recess; Length: anterior-to-posterior extent adjacent to transverse acetabular ligaments

Measurement modalityMRI most accurately measures labral width

Clinical relevanceLabral width influences suction seal and may guide reconstruction decisions

inv-101: Capsular plication — definition

Capsular plication — definitionArthroscopic procedure that sutures ligaments around the hip joint to increase stability

IndicationUsed to address instability or capsular laxity (e.g., atraumatic micro-instability, Ehlers-Danlos) as reported in cohort series

Outcome noteReported improvements in PROs in selected series; evidence level III–IV

inv-102: Borderline dysplasia (BD) — LCEA 18°–25°

Borderline dysplasia (BD) — LCEA rangeLateral center-edge angle (LCEA) 18°–25° used to define borderline acetabular dysplasia in cohort comparisons

Clinical implicationArthroscopy outcomes in BD reported as favorable in selected patients with complete capsular closure and labral repair

ContrastSevere dysplasia (LCEA <18°) associated with poor outcomes historically

inv-103: AIIS decompression (sub-spinal decompression) — definition

AIIS decompression — definitionArthroscopic resection of low/extended anterior-inferior iliac spine prominence to restore clearance between AIIS and acetabular rim

Surgical goalResect AIIS to ~2 burr widths above acetabular rim to achieve ~11 mm clearance and relieve sub-spinal impingement

EvidenceLimited evidence supports effectiveness; used when AIIS extension causes symptomatic impingement

inv-104: Borderline dysplasia (BD) repeat — LCEA approx 18°–25°

Borderline dysplasia repeat — LCEAAcetabular LCEA approximately 18° to 25° representing mild or borderline dysplasia as used in cited studies

Study useUsed to select cohorts for comparison against non-dysplastic patients (LCEA 25°–40°)

Management noteCareful selection and capsular management recommended in BD patients undergoing arthroscopy

inv-105: Iliopsoas impingement following THA — definition and evaluation context

Iliopsoas impingement after THA — definitionGroin pain during active hip flexion attributed to impingement between the iliopsoas tendon and the acetabular component; diagnosis supported by imaging and diagnostic injection

EvaluationAssess anterior component prominence on lateral radiograph and consider CT; diagnostic infiltration recommended before tenotomy

Treatment contextEndoscopic tenotomy can provide symptom relief when conservative measures fail and diagnostic workup excludes other causes

inv-106: Iliopsoas impingement / tendinopathy following THA — definition

Iliopsoas tendinopathy following THA — definitionGroin pain during hip flexion from iliopsoas tendon irritation/impingement on acetabular cup or prominence; diagnosis aided by imaging and injection

Surgical considerationEndoscopic/arthroscopic tenotomy reported to improve pain in selected patients failing conservative care for ≥6 months

Pre-operative stepsDocument failed conservative care, imaging of cup position/overhang and consider diagnostic infiltration prior to release

inv-107: Femoroacetabular impingement (FAI) — overall condition definition

FAI — definitionAbnormal contact between the femoral head/neck and the acetabulum causing labral and cartilage damage; includes cam, pincer, or combined types

Imaging roleDiagnosis relies on radiographs, MRI, or CT demonstrating cam/pincer morphology (alpha angle, center-edge angle, loss of head–neck offset)

Management spectrumRanges from conservative care (activity modification, NSAIDs, physiotherapy) to surgical interventions including arthroscopy, open osteochondroplasty, and reconstruction

Femoro-Acetabular Surgery for Hip Impingement Syndrome

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Coverage Criteria for Femoro‑acetabular Surgery (FAI)

Coding and Measurement Thresholds

Provider Actions, Prior Authorization & Documentation

Background and Condition Description

Definitions and Measurement Concepts

Policy Revision History