CurrentColorado Rocky Mountain Health PlansPolicy CS056OH.F

Surgery of the Hip (for Ohio Only)

Medical policy governing surgical treatment of the hip, including procedures for Femoroacetabular Impingement (FAI) Syndrome, applicable to Ohio members and their providers.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicySurgery of the Hip (for Ohio Only)

Policy CodePolicy CS056OH.F

Change TypeClarifications to definitions and references

Effective Date04/01/2026

Next Review Date

Key ActionObtain prior authorization using InterQual procedure modules to document medical necessity for hip surgeries.

SourceLink

POLICY UPDATE CHANGES

Updated definition of 'Radiographic Findings of Osteoarthritis'.

Updated References section to reflect the most current information.

InterQualprimary clinical criteria source

Ohio-onlystate applicability

CS056OH.Fpolicy identifier

04/01/2026effective date

Coverage and Medical Necessity Criteria

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InterQual-based coverage

Covered when InterQual CP procedure criteria are met

InterQual-based coverage: Medical necessity and coverage for hip surgeries (diagnostic and surgical arthroscopy, arthrotomy, hemiarthroplasty, removal and replacement of total joint replacement, and total joint replacement) are determined using the listed InterQual CP procedure modules.

See InterQual CP: Arthroscopy, Diagnostic +/- Synovial Biopsy, Hip; Arthroscopy, Surgical, Hip; Arthroscopy, Surgical, Hip (Pediatric); Arthrotomy, Hip; Hemiarthroplasty, Hip; Removal and Replacement, Total Joint Replacement (TJR), Hip; Total Joint Replacement (TJR), Hip.

The following list(s) of procedure and/or diagnosis codes is provided for reference purposes only. Listing of a code in this policy does not imply that the service described by the code is a covered or non-covered health service; benefit coverage is determined by federal, state, or contractual requirements and applicable law. The inclusion of a code does not guarantee reimbursement or payment, and other policies and guidelines may apply.

This Medical Policy applies to the state of Ohio. Services stated as unproven or those subject to coverage or quantity limits will be evaluated for medical necessity using Ohio Administrative Code 5160-1-01 and other applicable federal, state (OAC), or contractual requirements. In the event of conflict, those federal, state, or contractual requirements govern.

Procedure and Billing Codes

Arthroscopy, Arthrotomy, FAI-related and Hemiarthroplasty CPTs (group 1)CPT

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)
27299	Unlisted procedure, pelvis or hip joint (i.e., capsular plication, gluteal tendon repair)
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 (i.e., capsular plication, gluteal tendon repair)

1–10 of 11

1/2

Total Joint Replacement and Revision CPTs (group 2)CPT

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
27138	Revision of total hip arthroplasty; femoral component only, with or without allograft

HCPCS codesHCPCS

S2118

Metal-on-metal total hip resurfacing, including acetabular and femoral components

WOMAC pain domain

ThresholdWOMAC pain domain > 40

Source study/exampleQuintana, 2009 (WOMAC scoring referenced in policy)

UseDefines 'Disabling Pain' for coverage and clinical assessment

WOMAC functional limitation domain

ThresholdWOMAC functional limitation domain > 40

Source study/exampleQuintana, 2009 (WOMAC scoring referenced in policy)

UseDefines 'Functional Disability' for coverage and clinical assessment

Alpha angle (radiographic)

ThresholdAlpha angle (radiographic) > 50 degrees

ContextIndicator of Cam-type femoroacetabular impingement (loss of femoral head sphericity)

UseRadiographic criterion supporting diagnosis of FAI

Lateral center edge angle

ThresholdLateral center edge angle > 40 degrees

ContextIndicator of Pincer-type femoroacetabular impingement (acetabular overcoverage)

UseRadiographic criterion supporting diagnosis of FAI

Prior Authorization and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required. Coverage and medical necessity are determined using InterQual procedures for hip surgeries (including arthroscopy, arthrotomy, hemiarthroplasty, and total joint replacement). Providers must obtain prior authorization before scheduling services when applicable.

InterQual CP: Arthroscopy, Diagnostic, +/- Synovial Biopsy, Hip
InterQual CP: Arthroscopy, Surgical, Hip
InterQual CP: Arthroscopy, Surgical, Hip (Pediatric)
InterQual CP: Arthrotomy, Hip
InterQual CP: Hemiarthroplasty, Hip
InterQual CP: Removal and Replacement, Total Joint Replacement (TJR), Hip
InterQual CP: Total Joint Replacement (TJR), Hip

Note

Provider Action

Submit authorization requests and supporting documentation promptly. Verify member benefits and any plan-specific requirements prior to performing services.

Documentation Required

Required Medical Record Elements

The patient's medical record must contain documentation that fully supports the medical necessity for the requested services. Required elements include, but are not limited to: relevant medical history, focused physical examination findings, prior conservative treatments and response (including duration and dates), results of pertinent diagnostic tests or procedures (e.g., imaging reports), and patient-reported outcome measures when applicable.

Denial Risk

Documentation Insufficiency — Denial Risk

Lack of sufficient medical record documentation may result in denial of the requested service or delay in authorization. Ensure records are legible, available on request, and include dates and provider signatures where required.

Background and Definitions

Femoroacetabular Impingement (FAI) Syndrome is caused by anatomic abnormalities of the hip—commonly described as pincer, cam, or combined morphologies—that produce abnormal contact between the acetabulum and femoral head/neck. This abnormal contact can result in labral tears and cartilage damage leading to hip pain, restriction of motion, functional limitation, and may contribute to the development or progression of osteoarthritis. Surgical treatments (including diagnostic and surgical arthroscopy, arthrotomy, hemiarthroplasty, and total hip arthroplasty) are considered proven and may be medically necessary in specific clinical circumstances; determinations are made using InterQual procedure criteria referenced by this policy.

Definition — Disabling Pain

DefinitionDisabling Pain is defined as Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain domain > 40.

SourcePolicy Definitions referencing Quintana, 2009

PurposeUsed to identify clinically significant pain for coverage decisions

Definition — Femoroacetabular Impingement (FAI) Syndrome

DefinitionFemoroacetabular Impingement (FAI) Syndrome: abnormal contact from hip morphology or bone overgrowth causing labral tears and cartilage breakdown; types include Pincer, Cam, and Combined.

Key radiographic featuresPincer: lateral center edge angle > 40°; Cam: alpha angle > 50°; other signs include coxa profunda or acetabular retroversion.

Clinical consequencesMay result in pain, limited internal rotation, limp, labral tears, and progressive cartilage damage/osteoarthritis.

Definition — Functional Disability

DefinitionFunctional Disability is defined as Western Ontario and McMaster Universities Arthritis Index (WOMAC) functional limitation domain > 40.

SourcePolicy Definitions referencing Quintana, 2009

PurposeUsed to identify significant functional impairment for coverage decisions

Definition — Hip Dysfunction and Osteoarthritis Outcome Score (HOOS)

DefinitionHip Dysfunction and Osteoarthritis Outcome Score (HOOS): a 43-question self-administered hip-specific questionnaire assessing pain, symptoms, function in daily living, function in sport/recreation, and hip-related quality of life.

StructureConsists of 43 questions in five subscales (pain, symptoms, ADL function, sport/recreation, quality of life).

UseCommonly used to evaluate interventions in individuals with hip dysfunction or osteoarthritis.

Definition — International Hip Outcome Tool (iHOT-33)

DefinitionInternational Hip Outcome Tool (iHOT-33): a 33-item patient-reported hip outcome measure with four subscales, each item scored 0–100 and the final score averaged across items.

SubscalesSymptoms/functional limitations (16 items), sports/recreation (6), job-related (4), social/emotional/lifestyle (7).

ScoringEach item scored 0–100; final score is sum of item points divided by 33.

Definition — Outerbridge Grades

DefinitionOuterbridge Grades: cartilage lesion grading from 0 (normal) to IV (exposed subchondral bone).

Grade detailsGrade I: softening/swelling; Grade II: partial-thickness defect ≤1.5 cm; Grade III: fissuring to subchondral bone >1.5 cm; Grade IV: exposed subchondral bone.

UseUsed intraoperatively to classify severity of chondral injury.

Definition — Radiographic Findings of Osteoarthritis

DefinitionRadiographic Findings of Osteoarthritis: narrowing of joint space, osteophyte formation, subchondral sclerosis, subchondral cysts, deformity of bony end-plates, and thinning or complete loss of articular cartilage.

SourceACR, 2025 (as cited in policy definitions)

UseRadiographic features used to identify osteoarthritic changes relevant to surgical decision-making.

Definition — Tönnis Classification of Osteoarthritis

DefinitionTönnis Classification of Osteoarthritis: radiographic OA grading from 0 (none) to 3 (severe changes, obliteration of joint space).

Grade summaryGrade 0: no OA; Grade 1: slight sclerosis/slight joint space narrowing; Grade 2: small cysts/moderate joint space narrowing; Grade 3: large cysts/severe narrowing or obliteration of joint space.

UseUsed to categorize radiographic severity of hip osteoarthritis for clinical and coverage considerations.

OpenPayer

Surgery of the Hip (for Ohio Only)

Coverage and Medical Necessity Criteria

Procedure and Billing Codes

Prior Authorization and Documentation Requirements

Background and Definitions

Policy Changes and Revision History