Currentsierra health and lifePolicy 2026T0503JJ

Surgery of the Hip and Femoroacetabular Impingement (FAI) Syndrome

This policy governs medical necessity and coverage criteria for surgical treatment of the hip, including arthroscopic and open procedures for Femoroacetabular Impingement (FAI) Syndrome, and applies to Sierra Health and Life (UnitedHealthcare Commercial and Individual Exchange) members.

Policy Summary

Payersierra health and life

PolicySurgery of the Hip and Femoroacetabular Impingement (FAI) Syndrome

Policy CodePolicy 2026T0503JJ

Change TypeDefinitions updated

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionVerify member-specific benefit plan and obtain prior authorization per the member's plan before scheduling FAI surgical procedures.

SourceLink

POLICY UPDATE CHANGES

Updated definition of 'Radiographic Findings of Osteoarthritis' and refreshed references.

Tönnis 2–3Radiographic advanced OA exclusion

Outerbridge III–IVSevere cartilage damage exclusion

WOMAC >40Disabling pain threshold

29914-29916Principal arthroscopy codes

32%

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THA within 10 years (review)

8.9HOS ADL diff (FAIT 38 mo)

Coverage Criteria for Hip Surgery / FAI Syndrome

Medical necessity and exclusion for FAI surgery

Covered when clinical InterQual procedure-specific criteria are met and advanced joint disease is absent.

Primary coverage conditions: Surgical treatment of the hip and femoroacetabular impingement (FAI) is considered proven and medically necessary in certain circumstances per InterQual CP procedure-specific criteria (see Arthroscopy diagnostic/surgical hip, arthrotomy, hemiarthroplasty, and total joint replacement modules).Refer to InterQual CP modules for specific clinical requirements

Providers should reference the InterQual procedure-specific criteria for detailed clinical entry, continuation, and discharge criteria.

Exclusionary disease state: Surgical treatment for FAI Syndrome is NOT medically necessary when advanced osteoarthritis or severe cartilage damage is present.Tönnis Grade 2 or 3 and/or Outerbridge Grade III or IV

Presence of these findings is exclusionary to coverage for procedures intended to treat FAI.

Evidence-based considerations

Summary of clinical evidence and implications for selecting arthroscopic surgery versus nonoperative care in patients without advanced osteoarthritis.

Randomized and meta-analytic evidence: Multiple randomized trials and meta-analyses report that hip arthroscopy can provide superior short- to mid-term improvements in patient-reported outcomes (e.g., HOS ADL, iHOT-33, HOOS) and MRI measures of cartilage status compared with physiotherapy or conservative care in patients with FAI without advanced OA.

FAIT (Palmer et al.) found higher HOS ADL and lower SHOMRI at 38 months favoring arthroscopy but no difference in radiographic mJSW; other meta-analyses (Zhu, Mok, Kim, Gatz) found improvements in ADL, quality of life, and select PROMs with arthroscopy versus conservative therapy, while long-term data remain limited and heterogeneous.

Prognostic impact of radiographic OA: Presence of radiographic osteoarthritis is associated with higher failure rates and substantially higher rates of conversion to total hip arthroplasty after surgical management of FAI.Conversion to THA ~37.3% with OA vs 9.7% without (pooled data)

These findings support excluding patients with advanced radiographic OA from FAI-directed arthroscopic procedures due to worse outcomes and higher likelihood of subsequent THA.

Surgical treatment for Femoroacetabular Impingement (FAI) Syndrome is considered unproven and not medically necessary when advanced osteoarthritis (Tönnis Grade 2 or 3) is present. This exclusion aligns with the policy's referenced InterQual criteria and applies to arthroscopic and open hip procedures when radiographic evidence demonstrates Tönnis Grade 2–3 changes.

Evidence indicates that patients with radiographic osteoarthritis fare worse after surgical management of FAI: pooled data show a significantly higher overall failure rate and a higher rate of conversion to total hip arthroplasty for FAI patients with radiographic OA versus those without (conversion rates reported as 37.3% vs 9.7%). These findings support more guarded expectations for improvement and higher likelihood of subsequent THA when OA is present.

FAI surgery is not medically necessary and is excluded when there is evidence of advanced OA (Tönnis Grade 2–3) or severe cartilage damage (Outerbridge Grade III–IV). The policy cites both the InterQual-referenced coverage rationale and supporting clinical literature showing worse outcomes and higher conversion to THA in patients with radiographic OA.

Procedure and Measurement Codes / Thresholds

Arthroscopy, Arthrotomy, Hemiarthroplasty, and TJR 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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1/2

FAI-specific arthroscopy and unlisted procedure 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-08: WOMAC pain/function threshold — numeric threshold for disabling symptoms

WOMAC pain domain thresholdWOMAC pain domain score > 40 defines Disabling Pain

WOMAC function domain thresholdWOMAC functional limitation domain score > 40 defines Functional Disability

Instrument referenceWOMAC is a 24-item self‑administered questionnaire with pain, stiffness, and physical function subscales (Quintana, 2009)

inv-09: Radiographic Lateral Center Edge Angle — key-value (pincer morphology threshold)

Lateral center edge angle (LCEA) threshold> 40 degrees indicates acetabular overcoverage (pincer morphology)

Imaging finding described

Prior Authorization, Documentation, and Provider Guidance

Prior Authorization

Code-level Prior Authorization Reference

Prior authorization may be required for hip arthroscopy and related procedures per the member's benefit plan. Verify code-level prior authorization requirements with the member's plan before scheduling services.

Prior authorization requirements are plan- and code-specific — confirm for CPT/HCPCS codes listed in the policy.
Iliopsoas tendon release, capsular repair/release, and intraoperative debridement are considered integral to primary hip procedure codes and are not separately reimbursable.

Prior Authorization

Prior Authorization — Verify with Member Plan

Prior authorization decisions must be verified with the member's benefit plan. This policy is informational and does not itself authorize services. Always check the member-specific benefit document and any applicable federal or state mandates prior to providing or scheduling services.

This medical policy does not guarantee authorization or payment; prior authorization, if required, must be obtained from the payer.

Background and Clinical Context

Femoroacetabular Impingement (FAI) Syndrome results from abnormal bony morphology of the hip that creates premature contact between the femur and acetabulum. The common morphological patterns are Pincer (acetabular overcoverage), Cam (loss of femoral head sphericity with increased alpha angle), and Combined deformities. This abnormal contact can produce labral tears and progressive cartilage damage, leading to activity-related groin pain, limited internal rotation, limp, and over time an increased risk of osteoarthritis.

Key Definitions and Grading Systems

inv-20: Femoroacetabular Impingement (FAI) Syndrome — definition and cause

DefinitionFemoroacetabular Impingement (FAI) Syndrome occurs from abnormal hip bony morphology due to hip formation at birth or bone overgrowth (bone spurs) around the femoral head and/or along the acetabulum causing abnormal contact and impaired smooth motion

Common consequencesMay result in labral tears, breakdown of articular cartilage, pain, stiffness, limited internal hip rotation, limp, and progressive joint damage

Morphologic typesPincer (acetabular overcoverage), Cam (loss of femoral head sphericity/alpha angle >50°), and Combined (both present)

inv-21: Disabling Pain / Functional Disability — defined as WOMAC pain or function domain score >40

Definition of Disabling Pain / Functional DisabilityDisabling Pain: WOMAC pain domain score > 40; Functional Disability: WOMAC function domain score > 40

Policy Summary

Payersierra health and life

PolicySurgery of the Hip and Femoroacetabular Impingement (FAI) Syndrome

Policy CodePolicy 2026T0503JJ

Change TypeDefinitions updated

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionVerify member-specific benefit plan and obtain prior authorization per the member's plan before scheduling FAI surgical procedures.

SourceLink

On This Page

threshold":"","note":"Clinical decision-making should weigh individual patient factors, prior conservative therapy, and the absence of exclusionary OA/cartilage damage when considering surgery.","children":[]}

Radiographic evidence of pincer includes overcoverage of the femoral head, coxa profunda, or acetabular retroversion

Source examplesReferenced in definition of Pincer-type FAI (Witstein et al., Pun et al.)

inv-10: Alpha angle — key-value (cam morphology threshold)

Alpha angle threshold> 50 degrees indicates loss of femoral head sphericity (cam morphology)

Morphology descriptionCam-type impingement: femoral head not round with bony prominence (bone spur) forming on edge of femoral head

Imaging used for diagnosisAlpha angle >50° cited as radiographic evidence of Cam-type FAI

When a Medicare NCD/LCD is absent, Medicare Advantage plans may use internal coverage determinations per CMS guidance.

Note

Conservative Therapy Considerations

Conservative therapy, including a trial of physiotherapy, should be considered as part of patient selection and documented in the medical record; evidence shows physiotherapy can improve symptoms and may be an appropriate first-line treatment for some patients with FAI.

Document duration and content of conservative therapy (e.g., physiotherapy program, duration, response to treatment).
Evidence supports symptom and function improvement with both surgery and physiotherapy; timing and patient selection should be individualized and recorded.

Documentation Required

Medical Records and Coding Documentation

Medical records and coding documentation may be required to determine whether the member meets clinical criteria for coverage. Include clinical findings, imaging reports (with Tönnis and Outerbridge grades when applicable), details of conservative therapy, and relevant procedure codes to support adjudication.

Include clinical history, physical exam findings, and objective imaging (radiographs, MRI) with documented Tönnis and/or Outerbridge grades when applicable.
List applicable CPT/HCPCS codes on requests and clarify whether ancillary procedures (e.g., iliopsoas release, capsular work, debridement) are integral to the primary procedure.
Medical records submitted for review do not guarantee coverage; benefits are determined by the member-specific plan document.

Documentation Required

Documentation and Plan Verification

Coverage decisions must reference the member-specific benefit plan document; if there is a conflict between this policy and the member document or applicable law, the member document and law govern. Document the applicable coverage rationale in the medical record and authorization request.

Before finalizing coverage or scheduling, confirm benefit language and any state or federal mandates that may affect coverage.
If prior authorization is granted or denied, retain the authorization decision and the clinical rationale in the member's record.
When denying services based on advanced osteoarthritis or severe cartilage damage, document Tönnis Grade and/or Outerbridge Grade supporting the decision.

Denial Risk

Denial Risk: Advanced Osteoarthritis / Severe Cartilage Damage

Surgical treatment is unproven and not medically necessary for patients with advanced osteoarthritis (Tönnis Grade 2 or 3) and/or severe cartilage damage (Outerbridge Grade III or IV); highlight this risk of denial when applicable and document supporting imaging and grades.

If imaging documents Tönnis Grade 2–3 or Outerbridge III–IV, expect denial risk for arthroscopic FAI procedures — document thoroughly.
UHC accepts three or more moderate to severe radiographic findings as sufficient to support diagnosis of severe OA (see Radiographic Findings of Osteoarthritis).

WOMAC is a disease-specific, self-administered questionnaire for hip or knee osteoarthritis with pain, stiffness, and physical function dimensions

ReferenceThresholds cited to Quintana, 2009 in policy definitions

inv-22: HOOS / iHOT-33 — patient-reported outcome instruments described

HOOS descriptionHip Dysfunction and Osteoarthritis Outcome Score (HOOS): 43 items across five subscales — pain, symptoms, function in daily living, function in sport/recreation, and hip‑related quality of life

iHOT-33 descriptionInternational Hip Outcome Tool (iHOT-33): 33 items in four subscales (Symptoms/Function 16 items, Sport 6 items, Job 4 items, Social/Emotional/Lifestyle 7 items); items scored 0–100 with final score averaged

Use caseBoth are patient‑reported outcome measures commonly used to evaluate hip symptoms and function in FAI studies

inv-23: Outerbridge and Tönnis grading — cartilage and radiographic OA grading definitions

Outerbridge grading (cartilage)Grade 0: Normal; I: softening/swelling; II: partial‑thickness defect/fissures not to subchondral bone ≤1.5 cm; III: fissuring to subchondral bone >1.5 cm; IV: exposed subchondral bone

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 head sphericity; Grade 3: large cysts/severe joint space narrowing or obliteration and severe deformity

Radiographic OA findingsNarrowing of joint space, osteophytes, subchondral sclerosis/cysts, deformity of bony end‑plates, and thinning or loss of articular cartilage; ≥3 moderate–severe findings support severe OA diagnosis per UHC guidance

inv-24: Radiographic osteoarthritis (OA) — definition and association with higher failure / THA conversion; referenced in policy history

Radiographic OA definitionRadiographic findings include joint space narrowing, osteophyte formation, subchondral sclerosis or cysts, deformity of bony end‑plates, and thinning or complete loss of articular cartilage

Association with outcomesPresence of radiographic OA is correlated with higher overall failure rates and a higher rate of conversion to total hip arthroplasty after surgical management of FAI (pooled conversion: 37.3% with OA vs 9.7% without OA)

Policy history noteDefinition of 'Radiographic Findings of Osteoarthritis' was updated in the 03/01/2026 policy revision