CurrentPremera BluecrossPolicy N/A

Surgery for Groin Pain in Athletes

Defines coverage stance for surgical treatment of sports-related groin pain (athletic pubalgia/sports hernia) for Premera Blue Cross members; applies to procedures intended to treat chronic activity-related groin pain in athletes.

Policy Summary

PayerPremera Bluecross

PolicySurgery for Groin Pain in Athletes

Policy CodePolicy N/A

Change TypeAnnual review — no material change

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionVerify member benefits and obtain prior authorization per plan requirements before submitting claims for unlisted procedures.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

InvestigationalCoverage stance

≥3 monthsConservative treatment period

70%-90%Reported success rates

About 20%Proportion benefiting

UnchangedPolicy stability

Coverage Determinations

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Investigational / Not covered

Covered when ALL of the following are met

Investigational determination: Surgical treatment of groin pain in athletes (athletic pubalgia/Gilmore groin/osteitis pubis/pub ic inguinal pain syndrome/inguinal disruption/slap shot gut/sportsmen groin/footballers groin injury complex/hockey groin syndrome/athletic hernia/sports hernia/core muscle injury) is considered investigational.

Policy states surgery for groin pain in athletes is investigational; no clinical criteria are provided that would render it covered.

Surgical treatment of groin pain in athletes (also referred to as athletic pubalgia, Gilmore groin, osteitis pubis, pubic inguinal pain syndrome, inguinal disruption, sports hernia, core muscle injury, and related synonyms) is considered investigational and is excluded from coverage as a proven therapy.

The evidence base includes systematic reviews, randomized controlled trials, and large case series reporting outcomes such as symptoms, function, and treatment-related morbidity. Although some studies report high success rates for specific procedures (for example, reported success rates of about 70%–90% for rectus abdominis repair and posterior wall mesh reinforcement in select series, and earlier return-to-play with mesh in some RCTs), other data (including a large 2016 prospective series) found that only about 20% of patients with chronic groin pain benefit from inguinal surgery. Overall, study heterogeneity, limited quality, and inconsistent outcome measurement mean the evidence is insufficient to determine that surgical technologies for sports-related groin pain improve net health outcomes.

This policy was created on 09/08/2014 with a literature review through June 25, 2014 and initially stated that surgical treatment of athletic pubalgia is investigational. The policy has undergone annual reviews since then (with updates and additional references at multiple review dates) and the policy statement that surgery for groin pain in athletes is investigational has remained unchanged through the most recent annual review approved April 13, 2026.

The document includes routine annual literature surveillance and periodic updates to references and related policies; the policy history records multiple review dates with no change to the investigational coverage stance.

This medical policy does not apply to Medicare Advantage. Coverage and prior authorization requirements for Medicare Advantage members should be determined by consulting the member benefit booklet or contacting the member’s plan or customer service representative.

Provider Requirements and Operational Notes

Prior Authorization

Prior Authorization / Unlisted Procedure Coding

Prior Authorization may be required for unlisted procedure codes and other non-specific surgical codes. Submit a prior authorization request when billing unlisted CPT codes to allow medical review of the proposed procedure and associated documentation.

Affected codes: CPT 27299, 49659, 49999 (Unlisted procedure codes for pelvis/hip, laparoscopy hernia procedures, abdomen/peritoneum).
If a procedure is billed with an unlisted code, include operative report, preoperative and postoperative notes, and imaging to support the specific procedure performed.

Documentation Required

Diagnostic and Conservative Therapy Documentation

Document the diagnostic evaluation and all conservative therapies tried prior to surgical consideration. Clinical record should include history, focused physical examination findings excluding a standard inguinal hernia or isolated muscle strain, and relevant imaging (e.g., MRI or ultrasound) that rules out alternative causes of groin or lower abdominal pain.

History: onset, activity-related symptoms, prior treatments, and functional limitations.
Exam: findings consistent with groin pain in athletes and absence of standard inguinal hernia.
Imaging: MRI or ultrasound reports identifying soft-tissue or abdominal wall injury and excluding other sources such as stress fracture or femoroacetabular impingement.
Required documentation with any surgical claim: imaging, clinic notes, specialist consultation notes, and operative report.

Documentation Required

Conservative Therapy Before Surgery

Surgical treatment is typically considered only after an adequate trial of conservative care. Providers should ensure and document a minimum trial of targeted conservative management before pursuing surgery.

Typical conservative therapy duration: >= 3 months of targeted care (e.g., rest, icing, NSAIDs, and structured physical therapy emphasizing core and adductor strengthening and coordination).
For in-season professional athletes, short-term modalities such as corticosteroid injection or PRP may be used; document indication and duration.
Document response to conservative care, including objective functional improvement or failure to improve, before surgical authorization is requested.

Step Therapy

Step Therapy / Plan Applicability

Step therapy requirements are not specified in this section; however, conservative management and documentation of failed non‑operative care are emphasized as prerequisites to surgical consideration. Verify any plan-specific step therapy rules.

This section does not define a formal step-therapy sequence beyond recommending conservative care prior to surgery.
Always check member benefits for any additional step therapy, prior authorization or utilization management requirements that may apply.
Contact member services or consult the benefit booklet to confirm applicable plan-level requirements and limits.

Clinical Background

Sports-related groin pain (commonly termed athletic pubalgia or sports hernia) is a soft-tissue injury that produces activity-dependent lower abdominal and groin pain, most frequently affecting athletes participating in sports with rapid twisting and directional changes. The condition is heterogeneous in cause and terminology and may be referred to by multiple names (eg, Gilmore groin, pubic inguinal pain syndrome, core muscle injury).

Diagnosis is based primarily on clinical history and physical examination, supported by imaging such as MRI or ultrasound when indicated. Many cases improve with conservative management — including rest, ice, nonsteroidal anti-inflammatory drugs, and a rehabilitation program focused on core and adductor strengthening — and surgery is typically considered only after failure of an adequate trial of conservative therapy (commonly at least 3 months).

Surgical approaches described in the literature are varied (eg, rectus abdominis repair, posterior wall mesh reinforcement, and soft-tissue repair or release), but the heterogeneity of techniques and outcome measures contributes to uncertainty about which patients, if any, reliably benefit from operative interventions.

Definitions and Terminology

inv-16: Athletic pubalgia / sports hernia definition

DefinitionA soft-tissue injury causing activity-dependent lower abdominal and groin pain that is not due to a true hernia; commonly called athletic pubalgia or sports hernia.

Typical populationMost often diagnosed in males participating in sports with rapid twisting and sudden changes in direction (eg, soccer, hockey, football, wrestling).

Usual course and initial managementMost cases improve with conservative care (rest, ice, NSAIDs, and core-focused physical therapy).

Surgical approaches and policy stanceSurgical procedures on muscles, tendons, or nerves for this condition have been proposed but are considered investigational (unproven) by this policy.

inv-17: Groin pain categories — extra-articular vs intra-articular sources

Extra-articular (medial/inguinal) sourcesArise from structures outside the hip joint such as adductor muscles, iliopsoas, inguinal region, and pubic bone (eg, adductor-related or inguinal-related groin pain).

Intra-articular (hip-related) sourcesOriginate from inside the hip joint, most commonly femoroacetabular impingement (FAI), which can coexist with or contribute to groin pain.

Clinical implicationEvaluation should distinguish extra-articular versus intra-articular causes because they have different diagnostic and treatment pathways; FAI may be addressed concurrently or sequentially with groin-directed interventions.

inv-18: Terminology mapping — athletic pubalgia / sports hernia / inguinal disruption / core muscle injury

Common synonyms used in literatureAthletic pubalgia; sports hernia; Gilmore groin; athletic hernia; sportsmen groin; footballers groin; hockey groin syndrome; slap shot gut; pubic inguinal pain syndrome.

Terminology emphasizing anatomy/functionInguinal disruption; core muscle injury; pubic-related groin pain (terms used to describe chronic groin pain related to inguinal/core musculature).

Consensus recommendationA 2015 consensus recommended the umbrella term 'groin pain in athletes' with specific diagnostic categories (adductor-, iliopsoas-, inguinal-, and pubic-related), reflecting the heterogeneous terminology in the literature.

OpenPayer

Surgery for Groin Pain in Athletes

Coverage Determinations

Coding and Billing

Provider Requirements and Operational Notes

Clinical Background

Definitions and Terminology

27299	Unlisted procedure, pelvis or hip joint
49659	Unlisted laparoscopy procedure, hernioplasty, herniorrhaphy, herniotomy
49999	Unlisted procedure, abdomen, peritoneum and omentum