CurrentUnitedHealthcarePolicy N/A

Surgery of the Hip (including Femoroacetabular Impingement treatment)

UnitedHealthcare medical policy applicable to Idaho (including Idaho Medicaid Plus) addressing coverage rationale for hip surgery and surgical treatment for Femoroacetabular Impingement (FAI) Syndrome, referenced to InterQual procedures and listing applicable CPT/HCPCS codes and clinical definitions/evidence. It documents when surgical treatment is considered proven/medically necessary and when it is unproven/not medically necessary.

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Hip (including Femoroacetabular Impingement treatment)

Policy CodePolicy N/A

Change TypeNew policy

Effective DateJun 1, 2025

Next Review Date

Key ActionProviders must refer to and document that the member meets InterQual Clinical Preference (CP) criteria for the specific hip procedure requested to support medical necessity.

POLICY UPDATE CHANGES

New Medical Policy created effective 06/01/2025.

2Primary coverage stance items

15CPT/HCPCS codes listed

Coverage Summary

UnitedHealthcare medical policy for Surgery of the Hip (Idaho only) addressing surgical treatment for Femoroacetabular Impingement (FAI) Syndrome and related hip procedures. Scope: applicable to Idaho, including Idaho Medicaid Plus, and references InterQual clinical preference (CP) criteria for hip procedures (arthroscopy — diagnostic and surgical, arthrotomy, hemiarthroplasty, and total joint replacement). Coverage stance (high-level): mixed — procedures are proven and medically necessary when InterQual CP criteria are met, but surgical treatment for FAI is unproven and not medically necessary when Tonnis Grade 2 or 3 (advanced osteoarthritis) or Outerbridge Grade III or IV (severe cartilage damage) are present. Effective date: 2025-06-01. Status: CURRENT.

Medical Necessity Criteria

Medically Necessary (general statement referencing InterQual criteria)

Covered when ALL of the following are met per InterQual CP Procedures referenced:

Member meets InterQual CP criteria for one of the listed procedures: Arthroscopy, Surgical, Hip; Arthroscopy, Diagnostic, +/- Synovial Biopsy, Hip; Arthroscopy, Surgical, Hip (Pediatric); Hemiarthroplasty; Arthrotomy, Hip; Removal and Replacement; Total Joint Replacement (TJR); Hip; Total Joint Replacement (TJR); Hip.

InterQual CP procedures referenced for medical necessity determination (providers must document member meets InterQual CP criteria).

Not Medically Necessary / Unproven

Surgical treatment for Femoroacetabular Impingement (FAI) Syndrome is unproven and not medically necessary when ANY of the following are present:

Advanced osteoarthritis defined as Tonnis Grade 2 or 3Tonnis Grade 2 or 3

Radiographic OA grading per Tonnis Classification; presence renders FAI surgery unproven/not medically necessary.

Severe cartilage damage defined as Outerbridge Grade III or IVOuterbridge Grade III or IV

Outerbridge cartilage grading; presence renders FAI surgery unproven/not medically necessary.

CPT / HCPCS Codes

Arthroscopy, Diagnostic, +/- Synovial Biopsy, Hip (reference codes)CPT

29860

Arthroscopy, hip, diagnostic with or without synovial biopsy (separate procedure)

Arthroscopy, Surgical, Hip (reference codes)CPT

29861	Arthroscopy, surgical; with removal of loose body or foreign body, hip
29862	Arthroscopy, hip, surgical; with debridement/shaving of articular cartilage (chondroplasty), abrasion arthroplasty, and/or resection of labrum
29863	Arthroscopy, hip, surgical; with synovectomy

Arthrotomy, HipCPT

27120

Acetabuloplasty (e.g., Whitman, Colonna, Haygroves, or cup type)

Hemiarthroplasty, HipCPT

27125

Hemiarthroplasty, hip, partial (e.g., femoral stem prosthesis, bipolar arthroplasty)

Removal and Replacement; Total Joint Replacement (TJR); HipCPT

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

FAI-specific arthroscopy and unlisted CPTsCPT

27299	Unlisted procedure, pelvis or hip joint
29914	Arthroscopy; surgical; with femoroplasty (i.e., treatment of cam lesion), hip
29915	Arthroscopy, hip, surgical; with acetabuloplasty (i.e., treatment of pincer lesion)
29916	Arthroscopy, hip, surgical; with labral repair
29999	Unlisted procedure, arthroscopy

HCPCS - Hip resurfacingHCPCS

S2118

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

Provider Actions / Authorization & Documentation

Documentation Required

Use InterQual criteria for medical necessity determination

Refer to and document that the member meets the InterQual Clinical Preference (CP) criteria for the specific hip procedure requested to support medical necessity.

Documentation Required

Document radiographic/cartilage status

Document radiographic osteoarthritis (Tonnis) grade and intraoperative cartilage (Outerbridge) grade in the medical record.

Tonnis Grade 2-3
Outerbridge Grade III-IV

Denial Risk

Denial if advanced OA or severe cartilage damage present for FAI surgery

Claims for surgical treatment of Femoroacetabular Impingement (FAI) may be denied when advanced osteoarthritis or severe cartilage damage is present.

Exclusion: Tonnis Grade 2 or 3 OR Outerbridge Grade III or IV

Documentation Required

Medical records may be required for review

Medical records and documentation may be requested to assess whether the member meets clinical criteria for coverage; submission of records does not guarantee coverage of the services requested.

Clinical Background & Evidence

Background: Femoroacetabular Impingement (FAI) Syndrome is caused by abnormal bony morphology or overgrowth leading to abnormal hip contact and damage; the three FAI types described are Pincer (acetabular overcoverage), Cam (loss of femoral head sphericity / femoral head spur), and Combined (Mixed) when both are present. Common patient-reported outcome measures used to evaluate hip interventions include the WOMAC (pain and function domains), the Hip dysfunction and Osteoarthritis Outcome Score (HOOS), and the International Hip Outcome Tool (iHOT-33).

Clinical evidence summary: Multiple trials and systematic reviews report that hip arthroscopy can produce statistically significant improvements in patient-reported outcomes (for example, iHOT-33 and HOOS subscales) compared with conservative therapy in some studies, but improvements often do not consistently exceed the minimal clinically important difference (MCID) and long-term benefits remain uncertain. Studies and meta-analyses identify worse outcomes and higher failure/ conversion-to-arthroplasty rates when radiographic osteoarthritis or more advanced cartilage disease are present, indicating radiographic OA correlates with poorer surgical outcomes.

Evidence (systematic reviews / meta-analyses): Multiple meta-analyses and systematic reviews (Lamo-Espinosa 2023; Zhu 2022; Mok 2021; Gatz 2020; Gohal 2019) report that arthroscopic hip surgery often shows statistical superiority over conservative treatments for some PROMs (e.g., iHOT-33, HOOS subscales) but the clinical relevance is uncertain because MCID is not consistently achieved and long-term benefit is not well established; several reviews also note that the presence of osteoarthritis is associated with higher failure and conversion to arthroplasty.

Term	Definition
WOMAC pain domain (Disabling Pain)	Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain domain > 40 (Quintana, 2009).
WOMAC functional limitation domain (Functional Disability)	Western Ontario and McMaster Universities Arthritis Index (WOMAC) functional limitation domain > 40 (Quintana, 2009).
Femoroacetabular Impingement (FAI) Syndrome	Impingement due to hip formation at birth or bone overgrowth (cam, pincer, combined) causing abnormal contact, labral tears, cartilage breakdown, pain, stiffness, limited internal rotation, and joint damage. Three types: Pincer, Cam, Combined.
Outerbridge Grades	Grade I: softening and swelling; Grade II: partial-thickness defect with fissures not reaching subchondral bone or ≤1.5 cm; Grade III: fissuring to subchondral bone >1.5 cm; Grade IV: exposed subchondral bone.
Tonnis Classification	Radiographic osteoarthritis grading: Grade 0 none; Grade 1 increased sclerosis or slight joint space narrowing; Grade 2 small cysts, moderate joint space narrowing and loss of head sphericity; Grade 3 large cysts, severe joint space narrowing or obliteration and severe deformity.

OpenPayer

Surgery of the Hip (including Femoroacetabular Impingement treatment)

Coverage Summary

Medical Necessity Criteria

CPT / HCPCS Codes

Provider Actions / Authorization & Documentation

Clinical Background & Evidence

Revision History