CurrentPremera BluecrossPolicy 7.01.592

MEDICAL POLICY 7.01.592 Surgical Treatment of Femoroacetabular Impingement

Defines medical necessity criteria for arthroscopic treatment of femoroacetabular impingement (FAI), documentation requirements, applicable CPT codes, definitions, evidence summary, and policy history for Premera Blue Cross policy 7.01.592 effective 2025-07-01.

Policy Summary

PayerPremera Bluecross

PolicyMEDICAL POLICY 7.01.592 Surgical Treatment of Femoroacetabular Impingement

Policy CodePolicy 7.01.592

Change TypeRevised (annual review; literature updated, statements unchanged)

Effective DateJul 1, 2025

Next Review Date

Key ActionSubmit office visit notes documenting history and physical exam (symptoms, conservative measures tried and failed, and positive impingement sign), and imaging evidence of FAI morphology including listed imaging indicators and cartilage status.

SourceLink

POLICY UPDATE CHANGES

New policy 7.01.592 replaces archived policy 7.01.118 and was approved June 11, 2024; effective changes notified 10/08/2024 and CPT codes 29914-29916 were added then 29916 later removed for clarity.

2Covered CPT codes

3+Required imaging indicators (one or more)

3Key exclusion findings

Coverage Summary

Scope: Defines medical necessity criteria for arthroscopic treatment of femoroacetabular impingement (FAI), documentation requirements, applicable CPT codes (notably 29914 and 29915), definitions, evidence summary, and policy history for Premera Blue Cross policy 7.01.592, effective 2025-07-01 for skeletally mature patients.

Coverage stance: Covered with criteria — arthroscopic treatment of FAI is covered when the policy’s medical necessity criteria are met in skeletally mature patients.

Key thresholds

Skeletal maturity / age>= 15 years (documented closure of growth plates)

Conservative therapy duration>= 3 months

Alpha angle> 50°

Joint space>= 2 mm required (joint space < 2 mm = advanced OA exclusion)

Medical Necessity Criteria

Arthroscopic treatment of femoroacetabular impingement - Medical Necessity

Arthroscopic treatment of FAI may be medically necessary when ALL of the following conditions have been met:

ALL of the following

Age: Candidates should be skeletally mature with documented closure of growth plates (greater than or equal to 15 years of age).>= 15 years
Skeletal maturity consideration; policy states adolescence around age 15.
Symptoms: Moderate-to-severe hip pain worsened by flexion activities (e.g., squatting or prolonged sitting) that significantly limits activities.
Symptom severity and functional limitation required.
Conservative therapy: Unresponsive to conservative therapy for at least 3 months, including activity modifications, restriction of athletic pursuits, and avoidance of symptomatic motion.>= 3 months
Conservative care defined in guidelines (rest, NSAIDs, activity modification, physical therapy).
Physical exam: Positive impingement signs on clinical examination (pain elicited with 90° of flexion and internal rotation and adduction of the femur / FADIR test) or positive FABER (Patrick's) test.
Appendix referenced for tests.
Imaging
- ONE or more of the following imaging indicators
  - Acetabular retroversion (overcoverage with crossover sign).
  - Coxa profunda or protrusion.
  - Acetabular rim damage: Damage of the acetabular rim.
  - Alpha angle: Femoral head-neck offset with an alpha angle > 50°.> 50°
  - Pistol grip deformity.
No advanced osteoarthritis: No evidence of advanced osteoarthritis defined as Tonnis grade 2 or 3, or joint space of less than 2 mm.>= 2 mm joint space required (joint space < 2 mm = exclusion)
Contraindicates surgery if advanced OA present.
No severe chondral damage: No evidence of severe (Outerbridge grade IV) chondral (cartilage) damage.Outerbridge grade < IV
Severe cartilage erosion to bone excludes coverage.

Arthroscopic labral repair

Note regarding labral repair

Arthroscopic repair of a labral tear is considered medically necessary either alone or as an adjunct to FAI surgery when medical necessity criteria are met.

Labral repair covered per policy statement.

Provider Actions & Documentation Requirements

Documentation Required

Medical record documentation required

Submit office visit notes documenting history and physical exam including: H&P with symptoms (moderate-to-severe hip pain worsened by flexion activities that limits activities), documentation of conservative measures tried and failed (≥3 months of activity modification, restriction of athletics, physical therapy, NSAIDs as appropriate), and a positive impingement sign on exam (FADIR or FABER). Include imaging evidence (X‑ray, MRI, or CT) showing FAI morphology with partial or full‑thickness labral tear and/or articular cartilage damage plus one or more imaging indicators (e.g., acetabular retroversion/crossover sign, coxa profunda/protrusion, damage of the acetabular rim, femoral head‑neck offset with alpha angle >50°, pistol‑grip deformity, positive wall sign). Document cartilage and joint status to exclude advanced osteoarthritis (no Tonnis grade 2–3 or joint space <2 mm) and no severe chondral damage (Outerbridge grade IV).

29914
29915

Prior Authorization

Medical necessity review

Services are subject to medical necessity determination and prior authorization review. Individual medical records submitted for review must document that all policy criteria are met (age/skeletal maturity, symptom severity, failed conservative therapy, positive impingement sign, imaging evidence of FAI morphology with listed imaging indicators, and absence of advanced OA or severe chondral damage).

29914
29915

Billing Rule

Procedure selection

Billing guidance: Arthroscopic femoroplasty (CPT 29914) corresponds to treatment of cam lesions; arthroscopic acetabuloplasty (CPT 29915) corresponds to treatment of pincer lesions. Arthroscopic labral repair is considered medically necessary and may be billed as an adjunct to FAI surgery when criteria are met.

29914 — Arthroscopy, hip, surgical; with femoroplasty (treatment of cam lesion)
29915 — Arthroscopy, hip, surgical; with acetabuloplasty (treatment of pincer lesion)

Background and Evidence Summary

Background: Femoroacetabular impingement (FAI) is an anatomic mismatch between the femoral head-neck and the acetabulum that can cause labral and articular cartilage damage and symptomatic hip pain.

Surgical osteoplasty intent and selection: Open or arthroscopic osteoplasty (including femoroplasty and acetabuloplasty) aims to relieve symptoms, improve hip motion, and prevent further joint damage by reshaping impinging bone; policy emphasizes selecting skeletally mature patients without advanced osteoarthritis and after unsuccessful conservative management.

Evidence summary

Adults symptomatic FAIEvidence sufficient that surgery improves net health outcome (systematic reviews and observational studies)

Adults asymptomatic FAIInsufficient evidence that surgery prevents development of osteoarthritis

Children ≤ 15 years symptomatic FAIInsufficient evidence due to small sample sizes and lack of comparative studies

Revision arthroscopyEvidence sufficient for improvement in net health outcome in selected individuals (systematic reviews of observational studies)

Definitions

Relevant clinical thresholds

Revision History

07/01/24policy_replacement

New policy 7.01.592 Surgical Treatment of Femoroacetabular Impingement replaces previously archived policy 7.01.118; approved June 11, 2024, with effective changes notified October 8, 2024 following 90-day provider notification.

12/01/24interim_review

Interim review approved November 11, 2024 with a minor edit removing CPT code 29916 from the policy for clarity; policy intent unchanged.

07/01/25annual_reviewLatest

Annual review approved June 23, 2025 updated literature through February 21, 2025; policy statements unchanged.