CurrentCignaPolicy 0522

Surgical treatment for athletic pubalgia (sports hernia)

Defines Cigna's coverage position on surgical treatment for athletic pubalgia (sports hernia), including literature background, coding guidance, and Medicare determination notes. Applies to health benefit plans administered by Cigna Companies, subject to plan language and jurisdictional mandates.

Policy Summary

PayerCigna

PolicySurgical treatment for athletic pubalgia (sports hernia)

Policy CodePolicy 0522

Change TypeClarified (annual review, no clinical changes)

Effective Date

Next Review DateJul 15, 202639d

Key ActionConfirm coverage per the customer's benefit plan and applicable laws; document failed conservative therapy when requesting coverage for surgery.

POLICY UPDATE CHANGES

Annual Review dated 7/15/2024 and 7/15/2025 noted; no clinical policy statement changes.

1Coverage stance: surgical treatment considered experimental/investigational/unproven

3Unlisted procedure CPT codes cited as experimental

0Medicare NCDs/LCDs identified

Coverage Summary

This policy addresses surgical treatment for athletic pubalgia (sports hernia) and the coverage position is: surgical treatment is considered experimental, investigational, or unproven and is not covered.

Policy Metadata

Policy Number0522

StatusCURRENT

Last Review2025-07-15

Next Review2026-07-15

Scope SummaryDefines Cigna's coverage position on surgical treatment for athletic pubalgia (sports hernia), including literature background, coding guidance, and Medicare determination notes. Applies to health benefit plans administered by Cigna Companies, subject to plan language and jurisdictional mandates.

Athletic pubalgia (sports hernia) is a poorly defined syndrome of chronic groin pain in athletes with varied terminology and heterogeneous diagnostic and surgical approaches; imaging and conservative management (rest, NSAIDs, physical therapy) are commonly used, and multiple surgical techniques have been proposed though the literature quality is low and inconsistent.

Medical Necessity / Coverage Determinations

Coverage Determination

Surgical treatment for athletic pubalgia is considered:

Surgical treatment for athletic pubalgia (sports hernia) is considered experimental, investigational or unproven.

Not Covered / Experimental Procedures

Surgical treatment for athletic pubalgia is explicitly considered experimental, investigational, or unproven by this coverage policy and therefore is not covered under the policy. Providers and reviewers should apply this determination when evaluating requests, recognizing that individual benefit plan terms and applicable laws/regulations may affect final coverage decisions.

Provider Actions & Documentation

Documentation Required

Reference plan language and medical necessity

Confirm coverage based on the specific customer's benefit plan document and applicable laws/regulations; coverage determinations require individualized review.

Documentation Required

Conservative treatment prior to surgery

Recognize that literature and policy emphasize attempting conservative management (rest, anti-inflammatory medications, physical therapy) before considering surgery; document failed conservative therapy when submitting requests (policy describes conservative management as standard prior to surgical consideration).

Individualized review is required for coverage decisions; when submitting requests, document attempts and failure of conservative therapy (rest, anti-inflammatory medications, physical therapy) and reference the specific customer benefit plan and applicable laws/regulations.

Background and Evidence Summary

Athletic pubalgia (also called sports hernia, Gilmore groin, or sportsman's hernia) is a complex, often under-recognized cause of chronic groin pain in athletes. Terminology and diagnostic criteria vary widely across the literature, and no single anatomic structure is consistently implicated in its development.

Diagnostic evaluation may include imaging (eg, radiographs, MRI, ultrasound) and physical exam. Conservative measures such as rest, anti-inflammatory medications, and physical therapy are commonly recommended; laparoscopic and open surgical procedures (eg, TEP, TAPP, open mesh or suture repairs, adductor tenotomy, rectus abdominis repair) have been described but the published studies are heterogeneous in methods and outcomes and generally of low quality, limiting clear conclusions about surgical effectiveness.

Evidence Item	Summary
Systematic reviews / RCTs cited	Multiple systematic reviews, meta-analyses and one small RCT are cited; overall evidence is heterogeneous and of low to moderate quality with limited high-quality comparative data.
Return to sport outcomes	Some reviews suggest surgery may allow earlier return to sport but evidence quality varies and conservative management often has higher quality evidence.

Medicare Determinations

No Medicare National Coverage Determination (NCD) was found for surgical treatment of athletic pubalgia.

No Medicare Local Coverage Determination (LCD) was found for surgical treatment of athletic pubalgia.

Revision History

2024-07-15clarified

Annual Review dated 7/15/2024 noted; no clinical policy statement changes. Revision Details state 'No clinical policy statement changes.' for this annual review; this was identified as a non-material change (is_material=false).

2025-07-15clarifiedLatest

Annual Review dated 7/15/2025 noted; no clinical policy statement changes. Revision Details state 'No clinical policy statement changes.' for this annual review; this was identified as a non-material change (is_material=false).