OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentAetnaPolicy 0736

Hip Preservation Surgery

Customize your policy alerts

Sign up for Aetna Policy 0736 alerts

Get alerted when Policy 0736 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

This Aetna clinical policy governs medical necessity and coverage for hip preservation procedures (femoro-acetabular surgery, hip arthroscopy, pelvic osteotomy) and related indications for members covered by Aetna.

Policy Summary

PayerAetna

PolicyHip Preservation Surgery

Policy CodePolicy 0736

Change TypeNo material change

Effective DateSep 21, 2007

Last ReviewJul 31, 2026

Next Review DateAug 26, 2027

Key ActionPrior authorization is required for listed CPT codes when selection criteria are met; providers must document imaging, failed conservative therapy, and clinical rationale.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>=6Minimum symptom duration (months)

>=2 mmJoint space requirement

<45Age limit for pelvic osteotomy

29861, 29863Example covered arthroscopy CPTs

07/31/2026Policy last review

Coverage Criteria

FAI surgery (open or arthroscopic)

Femoro-acetabular surgery (open or arthroscopic) is considered medically necessary when ALL of the following are met:

FAI surgery medical necessity: Diagnosis of definite femoro-acetabular impingement (FAI) by imaging showing labral pathology with one or more of: cam (alpha angle > 50°), pincer (acetabular retroversion or coxa profunda, center edge angle ≥ 40°), or pistol‑grip deformity; and

Moderate to severe symptoms typical of FAI (hip/groin pain worsened by flexion activities) with duration of at least 6 months; and

Positive impingement sign (pain with 90° hip flexion with adduction and internal rotation or with extension and external rotation); and

Failure of conservative treatment including activity modification, NSAIDs, injections, and at least 12 weeks of treatment in the past year with ≥6 weeks formal in‑person physical therapy (documented); and

Policy Summary

PayerAetna

PolicyHip Preservation Surgery

Policy CodePolicy 0736

Change TypeNo material change

Effective DateSep 21, 2007

Last ReviewJul 31, 2026

Next Review DateAug 26, 2027

Key ActionPrior authorization is required for listed CPT codes when selection criteria are met; providers must document imaging, failed conservative therapy, and clinical rationale.

SourceLink

On This Page

Absence of advanced osteoarthritis on pre‑operative imaging (Tönnis grade < 2) and absence of severe cartilage injury (Outerbridge grade III–IV); and

Absence of joint‑space narrowing on plain radiograph (joint space not less than 2 mm anywhere along the sourcil); and

No generalized joint laxity related to connective tissue disorders (e.g., Ehlers‑Danlos, Marfan) and no osteogenesis imperfecta; and

Other potential sources of hip pain have been ruled out.

Labral repair

Hip arthroscopy to repair a labral tear is considered medically necessary when:

Labral repair indications: Traumatic labral tears causing mechanical symptoms; OR labral repair performed as an adjunct to FAI surgery.

Patient selection for repair: Patient has no advanced degenerative changes (excluded in comparative studies: Tönnis grade >1, lateral sourcil height <2 mm, Outerbridge grade 4) and imaging/clinical findings support repair rather than resection.

Pelvic osteotomy

Pelvic osteotomy (e.g., periacetabular osteotomy) is considered medically necessary for acetabular dysplasia when ALL of the following are met:

Pelvic osteotomy criteria: Lateral center‑edge angle (LCEA) < 20° and/or Tönnis (acetabular) angle > 12°; and

No or at most mild osteoarthritis of the hip (Tönnis grade 0–1); and

Minimum 6 months of symptoms; and

Age under 45 years for adult indications (skeletally immature children assessed separately).

Other covered procedures

Procedures considered medically necessary in context when criteria are met include:

Other medically necessary procedures: Femoro‑acetabular surgery (open or arthroscopic) for FAI; hip arthroscopy to repair traumatic labral tears or as adjunct to FAI surgery; repair of complete gluteus medius tears; hip arthroscopy for removal of foreign bodies or loose bodies when no significant osteoarthritis (Tönnis 0–1); and hip arthroscopy for synovectomy in limited instances of inflammatory arthritis when no significant osteoarthritis is present.

Arthroscopy for loose bodies

Coverage for specific hip arthroscopy CPTs when selection criteria are met

Selection criteria for arthroscopy for loose body: Arthroscopy with removal of loose body (CPT 29861) is covered when there is documentation of a loose or foreign body in the hip supported by appropriate ICD‑10 diagnosis codes and clinical/imaging findings, and when no significant osteoarthritis is present (Tönnis 0–1).

Arthroscopy synovectomy (limited instances)

Coverage for synovectomy

Synovectomy coverage: Arthroscopic synovectomy (CPT 29863) is covered in limited instances of inflammatory arthritis when no significant osteoarthritis is present, with supporting ICD‑10 inflammatory arthritis diagnoses; synovectomy is not covered for debridement of trochanteric bursitis as an adjunct to FAI surgery.

General evidence-based considerations for FAI surgery

Evidence and outcomes considerations drawn from systematic reviews and cohort studies:

General evidence summary: The evidence base is primarily short‑ to mid‑term and largely Level III–IV observational studies and case series; many studies report pain reduction and functional improvement but long‑term effects on osteoarthritis progression or prevention of THA remain unproven.

Factors associated with better or worse outcomes

Patient and imaging factors that predict outcomes:

Predictors of better outcome: Preserved joint space (> 2 mm) and absence of advanced chondral damage are associated with improved survivorship and functional gains after hip arthroscopy.joint space > 2 mm

Predictors of worse outcome: Joint space ≤ 2 mm, advanced MRI/Outerbridge chondral grade, longer duration of pre‑operative symptoms, and pre‑existing advanced osteoarthritis predict poorer outcomes and higher rates of conversion to THA or surgical failure.joint space ≤ 2 mm

Labral management considerations

Evidence comparing labral treatments:

Repair vs resection: Comparative studies report superior clinical and radiographic outcomes with labral re‑attachment/repair versus labral resection in appropriately selected patients without advanced degenerative changes.

Outcomes in specific populations

Reported functional outcomes by subgroup:

Athletes: High‑level athletes show substantial return‑to‑play rates (e.g., 73%–95%) and significant improvements in hip outcome scores after arthroscopic treatment.

Adolescents: Small series report short‑term improvements in HOS and HHS after arthroscopic FAI surgery with low complication rates in limited cohorts.

Older patients: Patients ≥50 years may have symptomatic improvement but have higher subsequent THA rates, especially when joint space ≤ 2 mm; careful selection advised.age ≥50; joint space ≤ 2 mm

Evidence-informed coverage considerations

Coverage-relevant clinical factors supported by evidence in this section (informational):

Evidence of benefit: Short‑ and mid‑term improvements in pain and function are reported after arthroscopic/open FAI surgery in multiple observational studies; RCT evidence (3 trials, n≈650) shows superior hip‑specific QOL at 12 months versus non‑operative care.

Poor prognostic indicators: Radiographic arthritis or limited joint space (≤2 mm) at index procedure predict worse outcomes and higher rates of conversion to THA; document joint‑space measurements.

Surgical technique factors: Complete capsular repair/closure and labral repair/reconstruction are associated with improved short‑term sport‑specific outcomes in some series; document capsular management and labral procedure type.

Evidence gaps: Long‑term effect of FAI surgery on preventing or delaying osteoarthritis is uncertain; higher‑quality trials and longer follow‑up are needed.

Typical study-based eligibility for labral reconstruction

Labral reconstruction is described as appropriate in studies when ALL of the following are met:

Primary indications: Young, active patient with minimal or no osteoarthritis (Tönnis grade 0–1).Tonnis 0-1

Labral pathology: Deficient or irreparable labrum determined pre‑operatively or intra‑operatively (hypoplastic, ossified, previously resected, or poor tissue quality).

Surgical setting: Primary or revision surgery, with stronger consensus supporting reconstruction in revision cases.

Concomitant pathology: Concurrent FAI correction and other intra‑articular procedures may be performed; outcomes may be affected by chondral damage and concomitant procedures.

Indications and selection criteria

Covered when ALL of the following are met (evidence-supported indications and selection factors):

Indication and patient selection: Symptomatic FAI with an irreparable or deficient acetabular labrum and minimal or no advanced osteoarthritis (Tönnis grade 0–1); patient is an appropriate candidate for joint‑preserving surgery.Tonnis 0–1

Prior management and documentation: Failed conservative measures documented; pre‑operative imaging (eg, MRA) confirms labral pathology and irreparability; surgeon documents intra‑operative determination of irreparability and rationale for reconstruction and graft choice.

Graft selection considerations: Autograft (eg, ITB, hamstring) or allograft (eg, fascia lata, gracilis) may be used based on surgeon experience and patient factors; pooled analyses show no clear outcome difference by graft type alone.

Expectations and outcomes: Patients may achieve significant short‑ to mid‑term improvements in PROs and high return‑to‑sport rates in athletic cohorts; survivorship and conversion to THA vary across studies and long‑term data are limited.

Hip arthroscopy — context for favorable outcomes

Evidence-based conditions and context in which procedures had favorable outcomes in cited studies

Hip arthroscopy for FAI with borderline/mild dysplasia — observed favorable outcome conditions: Studies reported improved PROs when LCEA was in the borderline range (~18°–25°), labral refixation/repair and complete capsular closure were performed, and thorough radiographic analysis (alpha angle, FEAR index, AWI/PWI, Tönnis angle) guided selection; follow‑up typically ~2–4 years.

Iliopsoas tenotomy — context for favorable outcomes

Iliopsoas tenotomy/lengthening after THA — observed outcome conditions

Endoscopic/arthroscopic tenotomy for iliopsoas impingement: Studies report high rates of pain alleviation (~92–93%), improved functional scores, and low complication rates when tenotomy is performed after failed conservative management and when diagnosis is supported by imaging (component prominence on radiographs/CT) and/or positive diagnostic injection; degree of component prominence was associated with outcomes in some series.

Coverage criteria for endoscopic/arthroscopic iliopsoas tenotomy

Covered when ALL of the following are met

Primary clinical indications: Groin pain during active hip flexion; exclusion of other causes of groin pain; and inadequate pain relief after at least 6 months of conservative management.6 months

Diagnostic confirmation: Positive response to diagnostic image‑guided peritendinous injection and pre‑operative imaging (radiographs and/or CT) documenting cup position/overhang when available.

Surgical approach options: Endoscopic or arthroscopic iliopsoas tenotomy performed at the lesser trochanter or acetabular rim; choice individualized and comparative evidence limited.

Endoscopic iliopsoas tenotomy after THA — indications

Covered when ALL of the following are met

indications for tenotomy after THA: (1) Groin pain during active hip flexion; (2) other causes of groin pain excluded; (3) no pain relief after ≥6 months of conservative treatment; (4) supportive imaging assessment of cup position/overhang when available.

Arthroscopic/endoscopic iliopsoas tenotomy — expected outcomes

Contextual outcomes information (not coverage criteria)

outcomes: Systematic reviews and series report favorable outcomes for arthroscopic and endoscopic tenotomy with high success rates, low complication rates, and occasional need for revision or component revision when metalosis or significant component prominence is identified.

Ligamentum teres reconstruction (LTR) — indications and prognosis

Covered when ALL of the following are met

LTR indications: Symptomatic fully torn or dysfunctional ligamentum teres with symptomatic multi‑directional instability not treatable by osteotomy or capsular plication alone.

counseling on prognosis: Patients with underlying factors (e.g., Ehlers‑Danlos, prior failed surgery) have higher failure rates and should be counseled regarding prognosis.

Hip arthroscopy in generalized joint hypermobility (GJH)

Contextual summary

GJH outcomes: Systematic review evidence (Level IV) indicates patients with generalized joint hypermobility (GJH) can achieve significant PROM improvements and have revision and THA rates comparable to non‑GJH cohorts when labral repair and capsular closure are performed; heterogeneity limits pooled conclusions.

Hip arthroscopy for FAIS — obesity considerations

Contextual/coverage considerations

obesity impact: Obese patients demonstrate improvement from baseline after hip arthroscopy but have lower absolute post‑operative PROs, lower rates of achieving PASS/MCID, higher complication rates, and higher long‑term conversion to THA compared with non‑obese patients.

Arthroscopic hip surgery is considered experimental, investigational, or unproven for all indications not specifically listed as medically necessary. The policy lists multiple procedures and indications that remain unproven (for example, capsular plication, labrum reconstruction, autologous osteochondral mosaicplasty with femoral neck osteochondroplasty, and debridement/repair of the ligamentum teres when provided as an adjunct to FAI surgery) and therefore are not supported outside the stated covered indications.

Arthroscopic synovectomy (CPT 29863) is covered only in limited instances of inflammatory arthritis when no significant osteoarthritis is present (Tonnis 0–1). Synovectomy is not covered when performed for debridement of trochanteric bursitis as an adjunct to FAI surgery.

Many outcome studies excluded patients with severe pre-existing osteoarthritis or acetabular dysplasia, and series report higher failure rates in those with advanced degenerative change. Consequently, the evidence does not support arthroscopic hip procedures in patients with substantial pre-operative osteoarthritis.

A Washington State Health Technology assessment concluded there were insufficient data to assess the efficacy of FAI surgery compared with no surgery and determined the available evidence did not support coverage at the time of that review.

Several large cohort or multicenter series used exclusion criteria that omitted patients with lateral center-edge angle <20°, osteoarthritis (Tonnis grade >1), slipped capital femoral epiphysis, workers' compensation status, and other prior hip conditions — reflecting that study cohorts commonly excluded these higher-risk populations.

Reported series frequently excluded patients with hip dysplasia, advanced chondral damage, or significant arthritis; labral reconstruction literature commonly restricts inclusion to deficient or irreparable labra in patients without advanced degenerative disease.

Examples of study exclusion criteria include lateral center-edge angle <20°, osteoarthritis (Tonnis grade >1), prior slipped capital femoral epiphysis (SCFE), and workers' compensation status — criteria that remove many patients with more advanced or complex pathology from the evidence base.

Degenerative labral tears are typically a manifestation of early osteoarthritis, and there is a lack of adequate evidence that arthroscopic repair of degenerative labral tears improves outcomes; repair is favored for unstable tears in good-quality labral tissue, whereas degenerative tears may not benefit from routine refixation.

There is uncertainty regarding arthroscopic treatment of unstable borderline dysplasia subtypes (for example acetabular retroversion) and limited evidence supporting durable benefit; some studies cautioned that arthroscopy may not be appropriate without addressing the underlying dysplasia.

When cup protrusion or acetabular component overhang exceeds 8 mm, the literature notes that acetabular revision may be indicated rather than isolated iliopsoas tenotomy, as significant component malposition can be better addressed by revision.

Appendix-listed indications (acute femoral head/acetabular fractures, malunion, persistent pain from avascular necrosis or loose bodies, limited synovectomy for inflammatory arthritides, ligamentum teres injuries, synovial biopsy, etc.) are not excluded from consideration and are listed as additional medically necessary arthroscopic indications when documentation supports them.

A referenced health technology assessment (CVZ / Netherlands, 2010) concluded that femoroacetabular surgery did not meet scientific criteria for practice at the time of that review, which is cited as a negative HTA conclusion in the policy references.

Procedures intended for patients with moderate or worse osteoarthritis (Tonnis grade 2 or 3), including pelvic osteotomy in that context, are considered not medically necessary because evidence and clinical guidance restrict joint-preserving interventions to patients with minimal or no advanced arthritis.

Long-term efficacy of hip preservation procedures to alter the progression to osteoarthritis or to reliably prevent total hip arthroplasty is unproven; available data are predominantly observational with limited long-term follow-up.

Patients with advanced joint-space narrowing or advanced chondral damage have been reported to have poor outcomes and higher failure rates after arthroscopic procedures, including substantially higher failure/THA conversion rates compared with patients with preserved joint space.

Some systematic reviews and meta-analyses have found no clear superiority of surgical treatment over conservative care for disability or functional outcomes in the short- to medium-term; the quality of evidence varies and conclusions are mixed.

The overall quality of the evidence is limited: most studies are low-level (predominantly Level III–IV case series), heterogeneous in techniques, patient selection, graft types, and outcome measures, and lack randomized comparative data.

When the native labrum is judged reparable, repair or debridement with refixation is generally preferred over reconstruction; studies report superior clinical and radiographic outcomes with labral reattachment/repair compared with simple resection in appropriately selected patients without advanced degenerative change.

Isolated iliopsoas tenotomy without prior diagnostic image-guided injection, without adequate imaging assessment of component position/overhang, or without documentation of an adequate trial of conservative therapy is inconsistent with the evidence-based indications and may lead to poor outcomes or denial of coverage.

Outcomes of hip preservation procedures in patients with Ehlers‑Danlos syndrome and other hypermobility disorders are inconsistent; published series are small and show higher failure rates, so results should be interpreted cautiously and individualized counseling is recommended.

The policy lists specific CPT codes that may be covered when the stated selection criteria are met (for example, 29914, 29915, 29916, 27146–27158, and others). Coverage of these CPT codes depends on meeting the clinical criteria and documentation requirements described in the policy; prior authorization is expected for these procedures.

Coding

CPT codes covered if selection criteria are metCPTCovered

27146	Osteotomy, iliac, acetabular or innominate bone.
27147	with femoral osteotomy and with open reduction of hip.
27151	with femoral osteotomy.
27156	with femoral osteotomy and with open reduction of hip.
27158	Osteotomy, pelvis, bilateral (eg, congenital malformation).
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.

Other CPT/HCPCS codes mentionedmixed

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.
29861	Arthroscopy, hip, surgical; with removal of loose body or foreign body.
29863	Arthroscopy, hip, surgical; with synovectomy.
97161	Physical therapy evaluation (low complexity).
97162	Physical therapy evaluation (moderate complexity).
97163	Physical therapy evaluation (high complexity).
97164	Physical therapy re-evaluation.
S2115	Osteotomy, periacetabular, with internal fixation.

ICD-10 codes covered if selection criteria are met (examples)ICD-10Covered

M24.151	Other articular cartilage disorders, hip.
M25.551	Pain in hip.
M76.10	Psoas tendinitis.
Q65.00	Congenital deformities of hip.
R26.2	Difficulty in walking, not elsewhere classified.

ICD-10 codes not covered for indications listed in the CPB (examples)ICD-10Not Covered

M16.0	Osteoarthritis of hip.
Q78.0	Osteogenesis imperfecta.
Q79.60	Ehlers-Danlos syndrome.
Q87.40	Marfan's syndrome.

Covered CPT Codes (selected examples)CPTCovered

29861

Arthroscopy, hip, surgical; with removal of loose body or foreign body [when no significant osteoarthritis is present]

Covered CPT Codes (synovectomy)CPTCovered

29863

Arthroscopy, hip, surgical; with synovectomy [in limited instances of inflammatory arthritis when no significant osteoarthritis is present]

Applicable ICD-10 Codes (examples listed across chunks)ICD-10

M16.0 - M16.9	Osteoarthritis of hip [advanced osteoarthritis]
M24.051 - M24.059	Loose body in hip
S70.251A - S70.259S	Superficial foreign body of hip
S71.021A - S71.029S	Laceration with foreign body of hip
S71.041A - S71.049S	Puncture wound with foreign body of hip
Z18.81 - Z18.89	Other specified retained foreign body [hip]
Q78.0	Osteogenesis imperfecta
Q79.60	Ehlers-Danlos syndrome
Q87.40 - Q87.43	Marfan's syndrome

No explicit codes in this sectionmixed

No codes listed

No explicit codes in this document sectionmixed

No codes listed

No explicit codes in this sectionmixed

No codes listed

Codes referencedmixed

No codes listed

Symptom duration — key thresholds

Minimum symptom duration>= 6 months (FAI and pelvic osteotomy); pelvic osteotomy requires minimum 6 months of symptoms

Conservative therapy duration before surgeryAt least 12 weeks of treatment in the past year with >=6 weeks formal in-person physical therapy

Conservative therapy before iliopsoas tenotomy after THA>= 6 months of failed conservative treatment

Alpha angle threshold

Alpha angle threshold (cam)> 50 degrees

Imaging used to measure alpha angleMeasured on AP/lateral radiographs, MRI or CT (radiographic measurement at femoral head-neck junction)

Clinical associationIncreased alpha angle linked to cam morphology and cartilage lesions antero-superiorly

Center edge angle thresholds

Lateral Center Edge Angle (LCEA) for pincer>= 40 degrees suggests pincer impingement

LCEA for dysplasia (pelvic osteotomy)LCEA < 20 degrees (acetabular dysplasia)

Borderline dysplasia rangeLCEA approximately 18°–25° (used to define mild/borderline dysplasia)

Joint space width key value

Radiographic joint-space requirement for arthroscopy/FAI surgeries>= 2 mm anywhere along the sourcil (absence of joint space narrowing)

Preserved joint space definition>2 mm on radiographs associated with better survivorship and functional outcomes

Prognostic split>2 mm versus <=2 mm predicts survivorship and THA conversion rates

Age limit for pelvic osteotomy

Age limit for pelvic osteotomy (adult)Age under 45 years

Pelvic osteotomy osteoarthritis requirementNo or at most mild osteoarthritis (Tonnis 0 or 1) — moderate/worse (Tonnis 2 or 3) considered not medically necessary

Radiographic dysplasia thresholds for osteotomyLCEA <20° and/or Tonnis angle >12°

Center edge angle / Alpha angle (additional)

Center edge angle indicating pincer>= 40° (center edge angle) - suggests pincer impingement

Alpha angle indicating cam>50° (alpha angle) - commonly cited for cam impingement

Measurement modalitiesAngles measured on plain radiographs, MRI or CT imaging

Joint space width comparison

Joint space comparison for outcomesPreserved joint space >2 mm associated with improved survivorship; limited joint space <=2 mm associated with higher THA conversion

Five‑year survivorship evidenceCohort data: patients with >2 mm had longer mean survival (e.g., 88 months) vs limited joint space (~40 months)

Outcome measures affectedHOS-ADL/HOS-SS and other PROs significantly better with preserved joint space

Radiographic joint-space threshold reference

Radiographic joint-space threshold used in studies<= 2 mm versus > 2 mm (threshold differentiating preserved vs limited joint space)

Clinical implication<=2 mm predicts worse outcomes and higher failure/THA rates

Documentation expectationPre-operative radiographic joint-space measurement should be recorded to support selection

Acetabular cup protrusion threshold

Acetabular cup protrusion/overhang threshold> 8 mm — may prompt consideration of acetabular revision rather than isolated tenotomy

Tenotomy outcomes by prominenceSome series report symptom resolution with <10 mm prominence; success rates lower with >=10 mm in select cohorts

Diagnostic importanceImaging (radiograph/CT) measurement of cup overhang recommended prior to tenotomy

Provider Actions & Authorization Requirements

Prior Authorization

Prior authorization required for listed covered CPTs

Prior authorization is required for the CPT codes listed as covered when selection criteria are met; providers must meet the clinical criteria in the policy for coverage and submit authorization for those codes prior to the procedure.

Covered CPTs include 29914, 29915, 29916, 27146, 27147, 27151, 27156, 27158 (authorization required when selection criteria met).

Prior Authorization

Prior authorization expected for hip arthroscopy (e.g., 29861, 29863)

Prior authorization is expected for hip arthroscopy CPTs such as 29861 and 29863 when selection criteria (clinical symptoms, imaging findings, and relevant ICD-10 diagnoses) are met; authorization should document that radiologically proven pathology is present.

29861 (removal of loose body) and 29863 (synovectomy) may require prior authorization when clinical and imaging criteria are documented.
Diagnostic arthroscopy (29860) is generally not covered unless radiologically proven pathology meeting criteria is found.

Documentation Required

Require pre-op imaging documenting joint space and cartilage

Pre-operative imaging that documents joint-space width and cartilage status must be available to justify hip preservation surgery because survivorship and outcomes differ by joint space and advanced narrowing predicts poor outcomes.

Document measured joint-space width (e.g., >2 mm vs ≤2 mm) on plain radiograph of the pelvis.
Include imaging demonstrating cartilage status (Outerbridge grade) when relevant.

Documentation Required

Document pre-op imaging and operative technique (capsule, labrum)

Clinical documentation submitted for authorization should include pre-operative radiographic joint-space measurement and operative details of capsular management and labral procedure type to support medical necessity decisions.

Record whether capsular management was partial or complete closure.
Document whether labral repair, augmentation, or reconstruction is planned or performed.

Prior Authorization

Document irreparable/deficient labrum and patient selection for reconstruction

Prior authorization for labral reconstruction should include rationale that the patient is young/active with minimal arthritis (Tonnis 0–1) and evidence that the labrum is deficient or irreparable based on pre-operative imaging and intra-operative assessment.

State Tonnis grade and absence of advanced osteoarthritis.
Provide imaging (MRI/MRA) and note intra-operative determination of irreparability when applicable.

Prior Authorization

Include clinical rationale and detailed operative plan

Prior authorization should include the clinical rationale for the proposed procedure and an operative plan, listing indication (e.g., irreparable labrum), graft selection if applicable, prior nonoperative management, and any concurrent or prior hip surgeries.

Describe prior conservative treatments and duration.
Specify graft type (autograft vs allograft) and concomitant procedures.

Prior Authorization

Prior authorization: document evidence-based rationale for reconstruction

Evidence-informed authorization rationale should document that the labrum is irreparable or hypoplastic/nonviable and include imaging/labral assessment and prior conservative management consistent with study-based selection criteria.

Cite imaging findings and intra-operative notes that support irreparability.
Include documentation of failed nonoperative care per policy thresholds.

Prior Authorization

Prior authorization when AIIS decompression is planned

When AIIS (sub-spinal) decompression is part of the procedure, prior authorization should document the indication, pre-operative AIIS morphology, and the relationship of the AIIS to symptoms.

Provide pre-operative radiographic assessment of AIIS type and any missed signs on AP/lateral views.
Explain intra-operative findings linking AIIS morphology to symptoms.

Prior Authorization

Require imaging and failed conservative care documentation for authorization

Prior authorization for procedures such as FAI surgery with labral repair and endoscopic/arthroscopic iliopsoas tenotomy must include documentation of failed conservative care and relevant imaging findings as described in the literature.

Document prior nonoperative measures and duration (see conservative therapy requirements).
Include imaging evidence such as LCEA for dysplasia or component prominence for post-THA impingement.

Prior Authorization

Clinical authorization requirements for iliopsoas procedures

Clinical prior authorization requirements for iliopsoas procedures include documentation of persistent groin pain with positive diagnostic injection, exclusion of other causes, at least 6 months of failed conservative therapy, and pre-operative imaging measurements when available.

Provide results of image-guided peritendinous diagnostic injection.
Report radiographic or CT measurements of cup inclination, anteversion, and overhang.

Prior Authorization

Authorize appendix-listed arthroscopic indications with supporting documentation

Procedures listed in the appendix (additional arthroscopic indications) are considered medically necessary when documentation supports the specific indication and should be authorized accordingly.

Appendix-listed indications include acute femoral head/acetabular fractures, malunion, persistent pain from avascular necrosis or loose bodies, limited synovectomy for inflammatory arthritides, ligamentum teres injuries, and synovial biopsy.

Note

References section: no prior authorization directives

The references section contains bibliographic citations only and does not specify additional prior authorization requirements or documentation triggers.

Do not rely on the references section for authorization criteria; use the policy's coverage and documentation sections.

Note

Administrative prior authorization / coding note

Administrative notes in the policy reference Clinical Policy Bulletins and plan benefits; specific prior authorization or coding requirements may be governed by the member's plan and are not fully specified in the policy text.

Check plan-specific prior authorization portals and benefit documents for exact submission requirements.
Policy statements guide clinical criteria but do not substitute for plan-level authorization rules.

Step Therapy

Conservative therapy requirement before authorization

Conservative therapy must be attempted and documented before authorization for FAI surgery: at least 12 weeks of treatment in the past year with a minimum of 6 weeks being formal in-person physical therapy (not virtual), plus activity modification, NSAIDs, and injections where applicable.

PT must be confirmed by PT notes or member claims history.
Conservative measures include activity modification, NSAIDs, and intra-articular injections.

Step Therapy

Expect conservative therapy before surgery

Conservative management (activity modification, NSAIDs, physical therapy, core strengthening) is the mainstay and should be tried prior to surgical intervention for FAI; documentation of these measures is expected for authorization.

Document specific conservative modalities and duration in the medical record prior to surgery.

Documentation Required

Document prior conservative therapy and failure

Documentation must show prior nonoperative treatment failure because evidence is largely from case series; such documentation may be relevant prior to surgical authorization.

Include dates and types of prior treatments and objective evidence of persistent symptoms.

Note

Consider and document nonoperative care rationale

Providers should consider and document nonoperative care options because systematic reviews show mixed evidence and surgery may not be superior to conservative treatment in some timeframes.

Record rationale for proceeding to surgery despite mixed comparative evidence.

Step Therapy

Step therapy considerations (no explicit step-pathway)

Step therapy is not explicitly specified in the policy, but consensus respondents favored reconstruction over debridement in revision settings and reserved reconstruction in primary cases when the native labrum is reparable.

In primary cases, document reparability of the native labrum to justify repair versus reconstruction decisions.

Step Therapy

Sequence repair/debridement before reconstruction when labrum reparable

Therapy sequencing guidance: consider repair or debridement alternatives when the labrum is reparable; reserve reconstruction for irreparable or deficient labra, with sequencing informed by preoperative assessment and intra-operative findings.

Document pre-op labral quality and intra-op findings that support the chosen surgical approach.

Documentation Required

Consider labral size/quality when sequencing repair vs reconstruction

Surgical sequencing may depend on preoperative labral size and tissue quality; authors note labral width and tissue quality inform decisions and may support augmentation or reconstruction when labrum is diminutive or degenerative.

Include MRI measurements of labral width when available and intra-operative descriptions of tissue quality.

Step Therapy

Expect documented conservative therapy before arthroscopic interventions

Pre-operative conservative management is generally expected prior to arthroscopic interventions for FAI and labral pathology; documentation of these measures supports authorization and patient selection.

Document attempts at conservative measures and any specific reasons for expedited surgery (e.g., acute traumatic tear).

Step Therapy

Require conservative therapy trial before tenotomy

Conservative therapy should be attempted before tenotomy; studies report approximately 50% respond to non-surgical care, so tenotomy is reserved for non-responders and documentation of failed conservative care is expected.

Document nonoperative measures and their duration; indicate clinical course leading to consideration of tenotomy.

Step Therapy

Require ≥6 months conservative management prior to tenotomy after THA

Conservative therapy before surgery: tenotomy is typically reserved for non-responders to non-surgical management; document that at least 6 months of conservative therapy was attempted for post-THA iliopsoas tendinopathy.

For iliopsoas tendinopathy after THA, document ≥6 months of failed conservative treatment prior to tenotomy.

Denial Risk

Document ≥6 months conservative management before tenotomy (denial risk if absent)

Conservative management prior to tenotomy is indicated with at least 6 months of nonoperative care documented for iliopsoas tendinopathy following THA; lack of such documentation may trigger denial.

Include records of physiotherapy, injections, and other non-surgical measures attempted.

Note

No additional step therapy requirements specified here

This portion of the policy does not state additional step therapy requirements beyond the conservative care expectations already described; follow the documented conservative therapy thresholds in the policy.

No separate step-therapy protocol is defined in the references section.

Documentation Required

Document imaging measurements and prior PT for FAI/pelvic osteotomy

Required documentation for FAI and pelvic osteotomy includes imaging evidence of definite FAI (X-ray, MRI or CT) with labral pathology and specific radiographic measurements (e.g., alpha angle >50°, center edge angle ≥40° or LCEA <20°/Tonnis angle >12° for dysplasia), and confirmation of prior conservative treatment including at least 12 weeks of treatment in the past year with ≥6 weeks formal in-person physical therapy.

Report alpha angle, LCEA/center-edge angle, Tonnis angle, and joint-space width measurements.
Attach PT notes or claims history confirming in-person PT duration.

Documentation Required

Document and addend imaging report disagreements

If the operating surgeon disagrees with the official imaging report, document the disagreement, discuss it with the interpreting provider, and include a written addendum indicating agreement or disagreement with the operating surgeon.

Include the written addendum in the medical record submitted for authorization.

Documentation Required

Submit detailed clinical history and supportive imaging

Clinical and imaging documentation should include history, physical exam findings, and supportive radiographic studies (CT, MRI, plain radiographs, or MRA) showing indicators such as alpha angle, center edge angle, evidence of labral tear or cartilage damage, and symptom duration to support arthroscopic FAI management.

Record duration of symptoms (≥6 months when reported in literature) and positive impingement sign.
Attach relevant imaging reports and measurements.

Documentation Required

Document joint space and cartilage status pre-operatively

Pre-operative assessment should document joint-space measurement (e.g., >2 mm versus ≤2 mm) and cartilage status because these predict survivorship and likelihood of conversion to total hip replacement.

Include plain radiograph measurements along the sourcil and note Outerbridge cartilage grade when available.

Documentation Required

Record joint-space width (≤2 mm vs >2 mm) in documentation

Radiographic measurement of joint space (≤2 mm versus >2 mm) is an important documented predictor of outcomes and conversion to THA and should be recorded in the pre-operative record when relevant.

Note measured joint space in millimeters and reference grouping (preserved >2 mm vs limited ≤2 mm).

Documentation Required

Document intra-op determination of irreparable labrum to justify reconstruction

To justify reconstruction, documentation should include intra-operative determination that the native labrum is irreparable and provide preoperative and intraoperative findings, graft choice, concurrent procedures, and validated outcome measures when available.

Attach intra-operative notes describing labral tissue quality and rationale for reconstruction.
List graft type (autograft/allograft) and concomitant osteoplasty or capsular procedures.

Documentation Required

List indication, prior failed nonoperative therapy, and graft choice

Required clinical documentation for reconstruction should state the indication (irreparable labrum, minimal arthritis Tonnis 0–1), prior nonoperative treatment failure, graft type chosen (autograft vs allograft), and any concurrent procedures performed.

Provide baseline PROs and follow-up plan; include rationale for graft selection.

Documentation Required

Include PROs and labral tissue description in documentation

Suggested documentation elements include pre- and post-operative patient-reported outcome scores (e.g., mHHS, NAHS, HOS-SSS/HOS-ADL, iHOT-12), description of labral tissue quality/size, rationale for reconstruction versus repair, graft type/technique, and follow-up interval (studies report minimum 2 to 5 years).

Include MCID/PASS achievement where available and timeline for expected follow-up.

Documentation Required

Document pre-op CT and computer-assisted planning when used

Pre-operative CT may be used for detailed assessment of FAI morphology and for computer-assisted pre-operative planning; documentation of imaging and virtual planning should be included when navigation-assisted osteochondroplasty is used.

Attach CT-based planning files or reports when used for computer-assisted surgery.

Documentation Required

Include specific radiographic measurements and operative details

Radiographic measurements such as LCEA, alpha angle, FEAR index, AWI/PWI, and Tonnis angle and documentation of labral repair, cam decompression, and capsular closure or plication should be included in clinical records submitted for authorization and utilization review.

Report specific numeric values for LCEA, alpha angle, and joint-space width.
Note whether complete capsular closure was performed.

Documentation Required

Document diagnostic injection and CT when evaluating iliopsoas impingement

Pre-operative diagnostic ultrasonography-guided peritendinous injection and CT imaging were used in series of arthroscopic tenotomy; documenting these diagnostic steps may support the indication for tenotomy.

Provide results of diagnostic injection (response to injection) and CT measurements of cup overhang when available.

Documentation Required

Required clinical and imaging documentation for iliopsoas tenotomy

Required documentation for iliopsoas procedures should include history of groin pain during active hip flexion, exclusion of other causes of groin pain, failure of at least 6 months of conservative treatment, results of diagnostic image-guided peritendinous injection, and pre-operative imaging measurements (radiograph cup inclination/anteversion and CT cup overhang).

Record duration and specifics of conservative therapy and objective response to diagnostic injection.

Documentation Required

Document groin pain, failed conservative care, and cup position before tenotomy after THA

Pre-operative clinical and imaging documentation for tenotomy after THA should include history of groin pain with active hip flexion, exclusion of other causes, evidence of no pain relief after 6 months of conservative treatment, and pre-operative imaging measurements of cup inclination/anteversion and axial/sagittal cup overhang when evaluating component-related impingement.

Include CT-derived axial and sagittal overhang measurements if available.

Note

References do not add documentation or authorization requirements

The references section contains only bibliographic references and does not include additional documentation requirements or denial triggers; do not use it as the source of authorization criteria.

Use the policy's coverage and documentation sections for authorization requirements.

Note

Provider responsibility and administrative disclaimer

Providers are responsible for medical advice and treatment; the Clinical Policy Bulletin assists in administering plan benefits but does not guarantee coverage—coverage decisions are subject to plan benefits and medical necessity review.

Ensure plan-specific benefits and authorization rules are followed in addition to policy clinical criteria.

Denial Risk

Advanced osteoarthritis (Tonnis ≥2) or Outerbridge III/IV → noncoverage

Advanced osteoarthritis (Tonnis grade 2 or greater) or severe cartilage injury (Outerbridge III/IV) is an exclusion that triggers noncoverage for FAI surgery; presence of these findings should be documented and will likely result in denial for hip preservation procedures.

Document Tonnis grade and Outerbridge cartilage grade on pre-operative imaging.

Denial Risk

Denial risk if selection criteria or supporting ICD-10 diagnoses are not documented

Claims for hip arthroscopy procedures (for example, 29861, 29863) may be subject to denial if selection criteria and accompanying ICD-10 diagnoses and imaging/clinical documentation are not met or provided.

Ensure submitted ICD-10 codes reflect the documented indication (e.g., loose body, inflammatory arthritis) and that imaging confirms absence of significant OA when required.

Denial Risk

Risk of denial or poor outcome with advanced joint-space narrowing

Patients with advanced pre-operative joint space narrowing or advanced chondral damage have higher failure rates and are less likely to improve; lack of improvement or advanced narrowing may be cited in utilization review.

Provide joint-space measurements to demonstrate suitability for hip-preserving surgery.

Denial Risk

Insufficient evidence finding (Washington State) may prompt review

A Washington State assessment concluded there was insufficient evidence to assess the efficacy of FAI surgery compared with no surgery; this insufficient-evidence determination is noted in the policy and may prompt careful review of cases lacking strong supporting documentation.

Cases lacking clear selection criteria, imaging, and documentation of conservative management may be subject to additional review.

Denial Risk

Insufficient evidence conclusion referenced (denial risk without documentation)

The Washington State Health Technology Clinical Committee's conclusion of insufficient evidence to cover FAI surgery is referenced in the policy and supports the expectation for rigorous documentation of selection criteria when seeking authorization.

Provide complete clinical and imaging justification given the noted evidence limitations.

Denial Risk

Evidence limitations may prompt additional utilization review

Because the evidence is limited largely to low-level studies with heterogeneity in techniques, graft types, and patient selection, insufficient documentation of irreparability, prior surgeries, or appropriate selection may trigger medical necessity review or denial.

Include detailed intra-operative findings and clear rationale when patient selection departs from commonly reported study criteria.

Denial Risk

Heterogeneous selection or prior surgeries may trigger medical review

Heterogeneous patient selection, prior surgeries, or concurrent procedures may limit generalizability of the evidence; lack of high-quality supporting documentation in these contexts could lead to medical review or denial.

Document prior hip surgeries and rationale for repeat procedures or revisions.

Denial Risk

Document study-based exclusion factors; may contraindicate coverage

Study-based exclusion considerations (e.g., revision hip surgery, labral treatment limited to debridement, LCEA <20°, osteoarthritis Tonnis >1, slipped capital femoral epiphysis, workers' compensation status) reflect contexts where procedures may be less appropriate and should be documented if present.

If exclusionary features are present, provide justification or alternate plan (e.g., PAO for dysplasia, THA for advanced OA).

Denial Risk

Degenerative labral tears: limited support—document tear type and tissue quality

Arthroscopic repair of degenerative labral tears lacks adequate evidence of improved outcomes and may not be supported when tears are degenerative rather than unstable in a good-quality labrum; document tear chronicity and tissue quality.

Differentiate degenerative versus traumatic labral tears in the record and justify surgical approach accordingly.

Documentation Required

Technique/documentation risk: missing capsular repair or radiographic analysis

Failure to perform or document capsular repair or failure to analyze relevant radiographic signs (e.g., acetabular version, cam morphology, femoral version) may affect outcomes and could be considered in utilization review.

Include documentation of capsular management and pre-op radiographic analysis of version and morphology.

Prior Authorization

Require diagnostic image-guided injection before iliopsoas release

A diagnostic image-guided injection should be performed before iliopsoas release to confirm the source of symptoms; lack of appropriate diagnostic workup may risk suboptimal outcomes and could be a basis for denial.

Submit results of image-guided peritendinous injection (pain relief response) with the authorization request.

Denial Risk

Denial risk if ≥6 months conservative care not documented for post-THA iliopsoas tendinopathy

Failure to document at least 6 months of failed conservative therapy for iliopsoas tendinopathy following THA may trigger denial when surgery is performed without meeting this commonly-stated indication.

Document duration and content of conservative measures for post-THA iliopsoas tendinopathy (≥6 months).

Note

References do not introduce additional denial triggers

The references section contains bibliographic citations only and does not add denial triggers or authorization requirements beyond those stated in the coverage and documentation sections.

Use the policy body for authorization criteria; references are supportive literature.

Note

Administrative disclaimer: CPB guides benefits but does not guarantee coverage

Clinical Policy Bulletins are developed to assist in administering plan benefits and do not constitute a contract; coverage decisions are guided by plan benefits and medical necessity and may result in denial if plan criteria are not met.

Confirm member-specific benefits and authorization requirements in addition to meeting policy clinical criteria.

Background

Hip preservation procedures address femoro‑acetabular impingement (FAI), labral pathology, and acetabular dysplasia with the goal of relieving hip/groin pain and mechanical symptoms while attempting to preserve the native joint and avoid or delay total hip arthroplasty. Diagnosis and patient selection rely on clinical exam (positive impingement sign), imaging (X‑ray, MRI, CT, MRA) demonstrating labral pathology and morphologic features (e.g., alpha angle, center‑edge angle), and documentation of failure of appropriate conservative measures.

Definitions

Definite femoro-acetabular impingement (FAI)

Definite FAI definitionImaging-confirmed labral pathology plus one or more: cam (alpha angle >50°), pincer (acetabular retroversion or coxa profunda, center edge angle >=40°), or pistol‑grip deformity

Required imaging modalitiesX-ray, MRI or CT demonstrating labral pathology and bony morphology

Clinical correlationMust be associated with moderate–severe symptoms and positive impingement sign

Acetabular dysplasia (for pelvic osteotomy)

Acetabular dysplasia for pelvic osteotomyLCEA <20° and/or Tonnis angle >12°, Tonnis grade 0–1, and age <45 (adult)

Borderline vs true dysplasiaBorderline dysplasia LCEA ~18°–25°; true dysplasia LCEA <20°

Surgical contextPelvic osteotomy is indicated for dysplasia (not borderline) when criteria above are met

Cam impingement

Cam impingement definitionAspherical femoral head (loss of sphericity at head‑neck junction) often with increased alpha angle

Typical patientMore common in young athletic males

Radiographic featuresAlpha angle >50°, loss of head‑neck offset, osseous bump at femoral neck

Pincer impingement

Pincer impingement definitionExcessive acetabular coverage (deep acetabulum, coxa profunda) associated with increased center edge angle (>=40°)

Typical patientMore common in middle‑aged women

Radiographic featureCoxa profunda and LCEA >=40° predict pincer morphology

Alpha angle

Alpha angle — definitionRadiographic angle at the femoral head‑neck junction used to quantify cam deformity; >50° frequently cited as indicative of cam

Measurement modalitiesMeasured on radiographs, MRI or CT

Clinical relevanceHigher alpha angle associated with cartilage lesions and FAI symptoms

Acetabular labrum definition

Acetabular labrum — definitionA ring of fibrocartilage around the edge of the hip joint's articular surface

FunctionContributes to hip stability and suction seal; labral width influences suction effect

MeasurementLabral width measurable by MRI; width = chondro‑labral junction to labral tip

Joint space narrowing threshold (2 mm)

Joint space narrowing threshold (2 mm)2 mm joint‑space threshold: >2 mm associated with better survivorship; <=2 mm associated with worse outcomes and higher THA conversion

Evidence basisMultiple cohort studies report survivorship and THA conversion differences using 2 mm cutoff

DocumentationRadiographic measurement along the sourcil expected pre-operatively

Co-existing arthritic changes

Co-existing arthritic changes — definitionRadiographic or clinical arthritis present at time of index procedure; associated with significantly worse postoperative outcomes and higher conversion to THA

Examples of adverse findingsTonnis grade >=2 or Outerbridge grade III–IV cartilage injury indicate advanced disease

Impact on candidacyPresence of significant arthritis commonly excludes patients from arthroscopic preservation procedures

Preserved joint space definition (>2 mm)

Preserved joint space definitionJoint‑space width greater than 2 mm on radiographs; associated with better survivorship and functional outcomes after hip arthroscopy

Outcome implicationPreserved joint space linked to lower rates of conversion to THA

Measurement siteMeasured anywhere along the sourcil on pelvic radiograph

Abnormal femoral version (FV)

Abnormal femoral version (FV) — thresholdsRetroversion <5° or anteversion >20° considered abnormal FV

Outcome influenceSystematic review found abnormal FV did not significantly influence short‑term arthroscopic outcomes (evidence limited)

Measurement variabilityFV measured by CT or MRI; methods vary and can alter values

Irreparable labrum

Irreparable labrum — definitionLabrum judged intra‑operatively to be non‑salvageable or deficient due to hypoplasia, ossification, poor tissue quality, or prior excision

Common indicationsIrreparable/deficient labrum often primary indication for reconstruction in young patients with minimal arthritis

Documentation expectationSurgeon should document intra‑operative determination of irreparability for reconstruction authorization

Patient selection (reconstruction candidates)

Patient selection for reconstructionYoung, active patients with minimal/no osteoarthritis (Tonnis 0–1) and deficient or irreparable labrum are typical reconstruction candidates

Revision vs primaryReconstruction more strongly favored in revision cases; primary cases reserved for irreparable labra

Required documentationPre-op imaging confirming labral pathology and intra-op documentation supporting irreparability

Irreparable labrum (surgeon judgment)

Irreparable labrum — surgeon judgmentDetermination by the operating surgeon that labrum is nonamenable to repair due to poor tissue quality, ossification, or severe deficiency

Intra-operative basisMany studies use intra‑operative assessment of tissue quality to define irreparability

DocumentationSurgeon's intra‑operative notes and rationale should be recorded for authorization

Labral width/height/length definitions

Labral width — definitionWidth: distance from chondro‑labral junction to labral tip (triangular cross‑section)

Labral height — definitionHeight: distance from joint surface to peri‑labral recess (perpendicular to width)

Labral length — definitionLength: anterior to posterior extent adjacent to transverse acetabular ligaments

Capsular plication definition

Capsular plication — definitionArthroscopic suturing/imbrication of capsular ligaments to reduce laxity and augment hip stability (often with inferior shift)

IndicationsUsed for micro‑instability, generalized ligamentous laxity, or post‑arthroscopy instability

Intended effectImproves stability by tightening capsule and restoring screw‑home mechanism

Capsular plication technique

Capsular plication — techniqueArthroscopic imbrication and inferior shift of capsule with suturing to reduce laxity; may be combined with labral repair and osteoplasty

Therapeutic goalEnhance hip stability in extension and external rotation and treat micro‑instability

Evidence contextReported good outcomes in selected cohorts; technique details described in surgical reports

AIIS decompression (sub-spinal decompression)

AIIS decompression — definitionArthroscopic resection of hypertrophic bone of the anterior‑inferior iliac spine to relieve extra‑articular sub‑spinal impingement

Surgical goalRestore hip flexion and alleviate sub‑spinal impingement by resecting to a safe zone above acetabular rim

Technique noteResect AIIS to ~2 burr widths (≈11 mm clearance) above rim to create type I AIIS without injuring rectus femoris origin

Computer-assisted hip arthroscopic surgery

Computer‑assisted hip arthroscopic surgery — definitionUse of pre‑operative virtual osteochondroplasty planning and intra‑operative CT‑based navigation to guide osteochondroplasty for FAI

PurposePromote precise resection to avoid under‑ or over‑resection during osteochondroplasty

LimitationsRequires CT (radiation), navigation registration and potential additional incisions; accuracy validation needed

Borderline dysplasia (BD)

Borderline dysplasia (BD) — definitionLCEA approximately 18°–25° used to define mild/borderline acetabular dysplasia in studies

Outcome implicationArthroscopy may have favorable outcomes in BD when labral repair and complete capsular closure performed

DistinctionBD differs from true dysplasia (LCEA <20°) which may require osteotomy

Iliopsoas impingement (IPI) following THA

Iliopsoas impingement (IPI) after THA — definitionImpingement between acetabular component and iliopsoas tendon causing anterior groin pain; evaluation includes radiographs, CT and diagnostic injection

Typical diagnostic featuresPain with active hip flexion, positive response to image‑guided peritendinous injection, and imaging showing cup prominence/overhang

Management optionsConservative care, endoscopic/arthroscopic tenotomy, or acetabular revision if severe component malposition

Iliopsoas impingement / tendinopathy definition

Iliopsoas impingement / tendinopathy definitionGroin pain from mechanical irritation of the iliopsoas tendon against acetabular component or other structures after THA, diagnosed by symptoms, imaging, and diagnostic injection

SymptomsAnterior groin pain worsened by hip flexion; strength loss may be assessed

Diagnostic stepsUltrasound‑guided injection and CT/radiographs to assess cup overhang/inclination/anteversion

Endoscopic/arthroscopic iliopsoas tenotomy definition

Endoscopic/arthroscopic iliopsoas tenotomy — definitionSurgical release or lengthening of the iliopsoas tendon performed arthroscopically or endoscopically at the acetabular rim or lesser trochanter

Approach variantsRelease can be performed at central compartment (acetabular rim), peripheral, or at lesser trochanter; recurrence rates and strength recovery vary by level

Adjunct diagnosticsDiagnostic US‑guided peritendinous injection recommended pre‑operatively to confirm diagnosis

Tönnis Classification

Tönnis Classification — purposeRadiographic grading of osteoarthritis from Grade 0 (no signs) to Grade 3 (severe joint space narrowing/cysts/deformity)

Clinical useUsed to assess osteoarthritis severity for surgical candidacy (Tonnis >=2 generally excludes preservation procedures)

Grades summaryGrade 0–3 scale with increasing joint degeneration

Outerbridge Classification

Outerbridge Classification — purposeCartilage grading from Grade 0 (normal) to Grade IV (exposed subchondral bone)

Clinical useOuterbridge III–IV indicate severe cartilage injury that may preclude hip preservation surgery

Grades summaryGrade I–IV describe increasing cartilage damage

Femoroacetabular impingement (FAI) definition

Femoroacetabular impingement (FAI) — definitionHip condition characterized by abnormal contact between femoral head/neck and acetabulum (cam, pincer, or mixed) leading to labral/chondral damage

ComponentsCam: aspherical femoral head; Pincer: excessive acetabular coverage; Mixed: both features

DiagnosisRequires imaging (X‑ray, MRI, CT) plus clinical signs/symptoms such as positive impingement sign

Revision History

2007-09-21effective

Policy became effective.

2026-07-31last_reviewLatest

Policy underwent most recent review.

2027-08-26next_review

Planned next policy review date.