CurrentColorado Rocky Mountain Health PlansPolicy 2026T0503JJ

Surgery of the Hip / Femoroacetabular Impingement (FAI) Syndrome

Clinical coverage policy for surgical treatment of hip conditions, including arthroscopy and total hip arthroplasty, with specific guidance on femoroacetabular impingement (FAI) syndrome; applies to UnitedHealthcare Commercial and Individual Exchange benefit plans.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicySurgery of the Hip / Femoroacetabular Impingement (FAI) Syndrome

Policy CodePolicy 2026T0503JJ

Change TypeDefinitions clarified

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionVerify member-specific benefit plan and, when required, obtain prior authorization and medical records demonstrating that the patient meets InterQual clinical criteria and lacks advanced radiographic osteoarthritis (Tönnis Grade 2–3) or severe cartilage damage (Outerbridge III–IV).

SourceLink

POLICY UPDATE CHANGES

Updated definition of 'Radiographic Findings of Osteoarthritis' in Definitions.

Supporting Information references section updated to reflect most current information.

Tönnis ≥2Advanced OA exclusion

Outerbridge III–IVSevere cartilage exclusion

WOMAC >40Disabling pain threshold

29914-29916Common arthroscopy codes

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32%THA within 10 yrs

222FAIT RCT participants

Coverage Criteria for Hip / FAI Surgery

General Coverage Rationale

Covered when meeting medical necessity per referenced criteria:

InterQual reference: Surgery of the hip and surgical treatment for Femoroacetabular Impingement (FAI) Syndrome is proven and medically necessary in certain circumstances; for specific medical necessity clinical coverage criteria, refer to the InterQual CP procedures for diagnostic and surgical hip arthroscopy, arthrotomy, hemiarthroplasty, and total hip replacement.

Refer to InterQual for detailed inclusion/exclusion criteria.

Exclusion for advanced disease: Surgical treatment for FAI Syndrome is unproven and not medically necessary in the presence of advanced osteoarthritis (Tönnis Grade 2 or 3) and/or severe cartilage damage (Outerbridge Grade III or IV).Tönnis Grade >=2 OR Outerbridge Grade >=III

This is a denial condition for FAI surgery.

Clinical evidence summary and coverage considerations

Summary of clinical evidence and considerations influencing coverage decisions:

RCT and meta-analysis evidence of benefit: Multiple randomized trials and meta-analyses report that hip arthroscopy provides superior patient-reported outcomes (e.g., HOS-ADL, iHOT, HOOS) compared with physiotherapy or conservative care in short- to mid-term follow-up in several trials and pooled analyses.

Supported by FAIT RCT (Palmer et al.) and multiple meta-analyses (Zhu, Mok, Gatz); see cited trials for specifics.

Radiographic progression and mid-term structural outcomes: FAIT (three-year follow-up) found no difference in radiographic minimum joint space width between arthroscopy and physiotherapy at 38 months, though MRI measures (SHOMRI) favored arthroscopy; interpretation limited by loss to follow-up and mid-term assessment.

See Palmer et al. and cautionary interpretation noted in trial reports.

Effect modifiers and limitations: Outcomes are less favorable and failure/conversion rates higher when radiographic osteoarthritis is present; study limitations include short follow-up, heterogenous conservative protocols, variability in surgical technique, and cohort differences (e.g., predominance of cam morphology).

Lei et al. meta-analysis and other reviews report higher conversion to THA and worse outcomes with OA; longer-term data are limited.

Surgical treatment for Femoroacetabular Impingement (FAI) Syndrome is considered unproven and not medically necessary when there is evidence of advanced osteoarthritis (Tönnis Grade 2 or 3) and/or severe cartilage damage (Outerbridge Grade III or IV).

The presence of radiographic osteoarthritis in patients with FAI is associated with higher surgical failure rates and increased conversion to total hip arthroplasty; a pooled analysis reported conversion to total hip arthroplasty of 37.3% in the FAI-with-OA group versus 9.7% in the FAI-alone group, and overall worse outcomes after surgical management when OA is present.

Accordingly, surgical intervention for FAI is considered not medically necessary and may be denied when clinical evaluation and imaging demonstrate Tönnis Grade ≥ 2 radiographic osteoarthritis or Outerbridge Grade III–IV cartilage damage; these findings represent exclusion criteria for arthroscopic or joint-preserving hip procedures in this policy.

Clinical evidence indicates that surgical management of FAI in patients with radiographic OA carries a greater risk of treatment failure and subsequent need for total hip arthroplasty compared with patients without radiographic OA, and outcomes are generally poorer in the OA subgroup.

Procedure and Assessment Codes

Arthroscopy / Arthrotomy / Arthroplasty CodesCPT

29860	Arthroscopy, hip, diagnostic with or without synovial biopsy (separate procedure).
29861	Arthroscopy, hip, surgical; with removal of loose body or foreign body.
29862	Arthroscopy, hip, surgical; with debridement/shaving of articular cartilage (chondroplasty), abrasion arthroplasty, and/or resection of labrum.
29863	Arthroscopy, hip, surgical; with synovectomy.
27120	Acetabuloplasty; (e.g., Whitman, Colonna, Haygroves, or cup type).
27125	Hemiarthroplasty, hip, partial (e.g., femoral stem prosthesis, bipolar arthroplasty).
27130	Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft.
27132	Conversion of previous hip surgery to total hip arthroplasty, with or without autograft or allograft.
27134	Revision of total hip arthroplasty; both components, with or without autograft or allograft.
27137	Revision of total hip arthroplasty; acetabular component only, with or without autograft or allograft.

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FAI-specific Arthroscopy and Related CodesCPT | HCPCS

27299	Unlisted procedure, pelvis or hip joint.
29914	Arthroscopy, hip, surgical; with femoroplasty (i.e., treatment of cam lesion).
29915	Arthroscopy, hip, surgical; with acetabuloplasty (i.e., treatment of pincer lesion).
29916	Arthroscopy, hip, surgical; with labral repair.
29999	Unlisted procedure, arthroscopy.
S2118	Metal-on-metal total hip resurfacing, including acetabular and femoral components.

inv-09: WOMAC pain or function domain — threshold used to define disabling pain/functional limitation

WOMAC pain domain thresholdWOMAC pain domain > 40 (Quintana, 2009)

WOMAC function domain thresholdWOMAC functional limitation domain > 40 (Quintana, 2009)

WOMAC instrument descriptionDisease-specific, self-administered questionnaire with 24 items grouped into pain, stiffness, and physical function

Provider Actions, Documentation, and Billing Guidance

Billing Rule

Applicable procedure codes and bundling guidance

Applicable procedure and diagnosis codes are provided for reference and to guide billing/bundling decisions. Iliopsoas tendon release, capsular repair, and capsular release are considered integral to the primary hip procedure and are not separately reimbursable. Debridement during hip arthroscopy is integral to FAI surgery codes 29914, 29915, and 29916 and is not separately reimbursable. Review the member-specific benefit plan for coverage and reimbursement rules.

Integral procedures not separately reimbursable: iliopsoas tendon release, capsular repair, capsular release
Debridement during hip arthroscopy bundled with CPT 29914, 29915, 29916
Reference code lists: CPT 29860–29863, 29914–29916, 29999; CPT 27120, 27125, 27130, 27132, 27134, 27137, 27138; 27299; HCPCS S2118

Prior Authorization

Background and Evidence Context

Femoroacetabular impingement (FAI) results from anatomic hip morphology that causes abnormal contact between the femoral head/neck and the acetabulum. The major subtypes are Cam (loss of femoral head sphericity or increased alpha angle), Pincer (acetabular overcoverage), and Combined morphology. These bony abnormalities produce repetitive impingement that can lead to labral tears, progressive cartilage damage, and hip pain, which in turn inform consideration of arthroscopic osteoplasty, labral repair, or other surgical interventions in selected patients without advanced osteoarthritis.

Definitions and Clinical Thresholds

inv-19: Femoroacetabular Impingement (FAI) Syndrome — definition and typical pathologic consequences

DefinitionFemoroacetabular Impingement (FAI) Syndrome: abnormal hip morphology or bone overgrowth around the femoral head and/or acetabulum causing abnormal contact that can lead to labral tears and progressive articular cartilage breakdown (osteoarthritis).

Common subtypesPincer (acetabular overcoverage), Cam (loss of femoral head sphericity; alpha angle > 50°), Combined (mixed).

Typical clinical consequencesPain, stiffness, limited internal hip rotation, limping, labral tears, and progressive cartilage damage leading to OA.

inv-20: Disabling Pain / Functional Disability — defined using WOMAC domain score > 40

Disabling Pain definitionWOMAC pain domain score > 40 (Quintana, 2009).

Functional Disability definition

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicySurgery of the Hip / Femoroacetabular Impingement (FAI) Syndrome

Policy CodePolicy 2026T0503JJ

Change TypeDefinitions clarified

Effective DateMar 1, 2026

Next Review DateN/A

SourceLink

On This Page

Clinical application and management considerations: Arthroscopy may be considered for symptomatic FAI in patients without advanced radiographic OA when the goal is improved pain and function; conservative therapy is a reasonable first-line option and documentation of prior conservative management may be relevant for coverage decisions.

Synthesis of trial and meta-analysis findings; conservative therapy commonly used as initial management in trials and guidelines.

Verify prior authorization and criteria

Prior authorization may be required. Verify member coverage and obtain any required prior authorization before scheduling procedures. Use member-specific benefit documents and any applicable federal/state mandates to determine preauthorization requirements. Tools such as InterQual may be used to support clinical review and authorization decisions.

Check member-specific benefit plan for prior authorization requirements
Obtain prior authorization when required prior to elective hip arthroscopy or arthroplasty
Use InterQual criteria and third-party tools to support authorization reviews

Denial Risk

Denial risk for advanced OA or severe cartilage damage

Surgical treatment for FAI is unproven and not medically necessary in the presence of advanced osteoarthritis (Tönnis Grade 2–3) and/or severe cartilage damage (Outerbridge Grade III–IV). Procedures performed in these settings are at high risk for denial.

Denial risk when Tönnis Grade = 2 or 3
Denial risk when Outerbridge Grade = III or IV

Documentation Required

Plan documentation requirement

Coverage decisions must reference the member-specific benefit plan and applicable laws. Medical records may be requested to document that clinical criteria are met; submission of records does not guarantee coverage.

Member-specific benefit plan governs in case of conflict with this policy
Medical records may be required to substantiate clinically necessary indications
Check federal/state mandates that may affect coverage

Note

Refer to InterQual for clinical criteria

Refer to the InterQual® CP procedures criteria for medical necessity determinations for listed hip procedures (diagnostic and surgical hip arthroscopy, arthrotomy, hemiarthroplasty, total hip arthroplasty and revisions). InterQual may be used as an objective evidence-based tool to assist coverage decisions.

InterQual CP criteria for: diagnostic hip arthroscopy (29860), surgical hip arthroscopy (29861–29863), arthrotomy (27120), hemiarthroplasty (27125), total hip arthroplasty and revisions (27130, 27132, 27134–27138)
Use InterQual during prior authorization and medical necessity reviews

Step Therapy

Conservative therapy as initial management

Conservative therapy (e.g., physiotherapy) is generally recommended as first-line management for FAI prior to arthroscopy when clinically appropriate. Evidence supports physiotherapy as an initial treatment option and trials of nonoperative care should be documented before elective surgical intervention, unless contraindicated.

Document trials of conservative management such as supervised physiotherapy and activity modification
Consider duration and response to nonoperative therapy when evaluating medical necessity for arthroscopy

WOMAC functional limitation domain score > 40 (Quintana, 2009).

Source/InstrumentWestern Ontario and McMaster Universities Arthritis Index (WOMAC), a 24-item patient-reported instrument assessing pain, stiffness, and physical function.

inv-21: Outerbridge and Tönnis Grades — definitions for cartilage damage and radiographic OA severity

Outerbridge grading (cartilage damage)Grade 0: Normal; Grade I: softening and swelling; Grade II: partial-thickness defect & fissures not to subchondral bone or >1.5 cm; Grade III: fissuring to subchondral bone >1.5 cm; Grade IV: exposed subchondral bone head.

Tönnis classification (radiographic OA)Grade 0: no signs; Grade 1: slight sclerosis/joint space narrowing; Grade 2: small cysts, moderate joint space narrowing, moderate loss of sphericity; Grade 3: large cysts, severe joint space narrowing/obliteration, severe deformity.

Clinical relevanceTönnis Grades 2–3 and Outerbridge Grades III–IV indicate moderate to severe disease and are cited as conditions where FAI surgery is unproven/not medically necessary.

inv-22: Radiographic Findings of Osteoarthritis — updated definition referenced in Policy History

Radiographic features of OANarrowing of joint space, osteophyte formation, subchondral sclerosis, subchondral cysts, deformity of bony end-plates, and thinning or complete loss of articular cartilage (ACR, 2025).

Operational acceptance thresholdUHC will accept three or more moderate to severe radiographic findings as sufficient to support a diagnosis of severe osteoarthritis.

Policy updateDefinition of 'Radiographic Findings of Osteoarthritis' was updated in the policy Definitions section (see Policy History effective 03/01/2026).