CurrentPremera BluecrossPolicy BCBSA Ref. Policy: 7.01.142

Surgery for Groin Pain in Athletes

Defines coverage stance for surgical treatment of sports-related groin pain (athletic pubalgia/sports hernia/core muscle injury) and applies to providers submitting claims to Premera Bluecross.

Policy Summary

PayerPremera Bluecross

PolicySurgery for Groin Pain in Athletes

Policy CodePolicy BCBSA Ref. Policy: 7.01.142

Change TypeNo material change

Effective DateMay 1, 2026

Next Review Date

Key ActionConsult member benefits and obtain prior authorization when applicable; surgery for groin pain is considered investigational and is generally not covered.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

70-90%Reported success rates (systematic review)

about 20%Proportion benefiting (2016 series)

3 monthsMinimum conservative therapy before surgery

1571Systematic review sample size

AnnualPolicy review frequency

Coverage Criteria — Surgical Treatment for Groin Pain in Athletes

Investigational — Surgical treatment of groin pain in athletes

Covered when ALL of the following are met

Investigational stance: Surgical treatment of groin pain in athletes (also described as athletic pubalgia, Gilmore groin, osteitis pubis, pubic inguinal pain syndrome, inguinal disruption, slap shot gut, sportsmen groin, footballers groin injury complex, hockey groin syndrome, athletic hernia, sports hernia, or core muscle injury) is considered investigational.

Services for surgical treatment of groin pain in athletes are investigational per this policy and are not covered.

Surgical treatment for groin pain in athletes (terms include athletic pubalgia, sports hernia, core muscle injury, and related diagnoses) is designated investigational under this policy and therefore not covered.

This medical policy does not apply to Medicare Advantage. Providers and members with Medicare Advantage plans should consult plan-specific documents and representatives for coverage determinations.

Restating the policy position: surgical treatment of groin pain in athletes is considered investigational (not medically necessary) and is not supported for coverage by this policy.

Policy Summary

PayerPremera Bluecross

PolicySurgery for Groin Pain in Athletes

Policy CodePolicy BCBSA Ref. Policy: 7.01.142

Change TypeNo material change

Effective DateMay 1, 2026

Next Review Date

Key ActionConsult member benefits and obtain prior authorization when applicable; surgery for groin pain is considered investigational and is generally not covered.

SourceLink

On This Page

Provider Actions — Authorization, Documentation, and Billing

Prior Authorization

Prior Authorization — Verify Member Benefits

Verify prior authorization and member benefits before scheduling any surgical procedure for groin pain in athletes. Coverage varies by contract; some plans may require prior authorization for surgeries or may not cover investigational procedures. Contact the member benefit booklet or customer service for plan-specific information.

Prior authorization: confirm coverage and authorization requirements with member benefits prior to providing services
Investigational procedures (see policy coverage) may be subject to denial if not authorized

Documentation Required

Documentation to Support Surgical Consideration

Document clinical decision-making thoroughly if surgical treatment is being considered. The medical record should include: a clear diagnosis based on history and physical exam; imaging results (MRI or ultrasound) that exclude other causes of groin or lower abdominal pain and document soft-tissue findings; prior conservative treatment details (type, duration, response); and rationale for surgery.

Diagnosis based primarily on history, physical exam, and imaging (MRI or ultrasound)
Exclude other sources of pain (e.g., stress fracture, femoroacetabular impingement, labral tear)
Record specifics of prior conservative care and documented failure

Note

Benefit Verification — Consult Member Contract

Coverage is subject to the terms, limitations, and conditions of the member's benefit plan. Before proceeding, verify benefits and any applicable limitations or exclusions that might affect payment for evaluation or treatment of groin pain in athletes.

Consult the member benefit booklet or contact customer service for benefit verification
Benefit limitations may trigger denial even when clinical documentation supports the service

Step Therapy

Conservative Therapy Required Before Surgery

Conservative therapy is required and should be documented before considering surgical options. Most individuals improve with nonoperative care; surgery is typically reserved for those who fail an adequate course of conservative management.

Conservative measures include rest, ice, NSAIDs, and a focused rehabilitation program
For most patients, at least 3 months of conservative treatment is expected before surgical consideration

Note

Conservative Therapy Emphasized in Literature

The evidence emphasizes nonoperative active training programs focused on core and pelvic muscle strength and coordination. Randomized trials and long-term follow-up studies support active physical training over standard therapy for many athletes with chronic groin pain.

Active training physical therapy programs (strength and coordination of core and adductor muscles) have shown superior return-to-sport and long-term outcomes compared with standard PT
For in-season professional athletes, targeted injections (e.g., corticosteroid, PRP) or short corticosteroid bursts have been used as adjuncts

Definitions — Terms and Synonyms

Athletic pubalgia / sports hernia — definition and clinical features

TermAthletic pubalgia (sports hernia)

DefinitionDisabling, activity-dependent lower abdominal and groin pain due to soft-tissue injury — not a true hernia.

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

Common clinical featuresActivity-related groin or lower abdominal pain; symptom provocation with sport-specific movements; frequently overlaps with other groin pathologies (adductor-, iliopsoas-, inguinal-, or pubic-related pain).

DiagnosisBased on history and physical examination, supported by imaging when indicated (eg, MRI or ultrasound).

Initial managementMost cases improve with conservative measures: rest, ice, NSAIDs, and targeted physical therapy focusing on core/pelvic muscles.

Athletic pubalgia / sports hernia — alternate terms used variably in the literature (core muscle injury, inguinal disruption)

Alternate terms (examples)Sports hernia; athletic hernia; core muscle injury; inguinal disruption; Gilmore groin; osteitis pubis; pubic inguinal pain syndrome; sportsmen groin; footballers groin; hockey groin syndrome; slap shot gut.

Terminology variation (evidence)Systematic review of 1571 individuals found the most common terms were 'athletic pubalgia' then 'sports hernia', reflecting wide variation in terminology across studies.

Consensus recommendation2015 Doha agreement recommended the general term 'groin pain in athletes' with specific diagnostic categories (eg, adductor-related, iliopsoas-related, inguinal-related, pubic-related).

ImplicationTerminology is inconsistent in the literature; similar clinical syndromes may be reported under different names, affecting interpretation of outcomes and comparisons across studies.

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

OpenPayer

Surgery for Groin Pain in Athletes

Coverage Criteria — Surgical Treatment for Groin Pain in Athletes

Coding — Relevant Procedure Codes

Provider Actions — Authorization, Documentation, and Billing

Background — Sports-Related Groin Pain

Definitions — Terms and Synonyms