ModifiedUnitedHealthcarePolicy CSOS6KS.02

Surgery of the Hip (for Kansas Only)

UnitedHealthcare medical policy applying only to Kansas that outlines coverage rationale, definitions, references, and applicable procedure/diagnosis codes for hip surgery including surgical treatment for Femoroacetabular Impingement (FAI) Syndrome; refers to InterQual criteria for specific medical necessity determinations.

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Hip (for Kansas Only)

Policy CodePolicy CSOS6KS.02

Change TypeSupporting Information Added

Effective DateAug 1, 2025

Next Review Date

Key ActionProviders must refer to and document compliance with the applicable InterQual clinical procedural (CP) criteria for the specific hip procedure requested to support medical necessity determinations.

POLICY UPDATE CHANGES

Medical Records Documentation Used for Reviews language was added clarifying that benefit coverage is determined by federal, state, or contractual requirements and that medical records documentation may be required but does not guarantee coverage.

16Referenced Procedure/HCPCS Codes

State-limitedGeographic Scope

InterQualPrimary clinical criteria source

Coverage Summary

Scope: UnitedHealthcare medical policy applying only to Kansas that outlines coverage rationale, definitions, references, and applicable procedure/diagnosis codes for Surgery of the Hip, including surgical treatment for Femoroacetabular Impingement (FAI) Syndrome. Coverage is mixed: hip surgery and surgical treatment for FAI are proven and medically necessary in certain circumstances, but specific procedure coverage requires meeting InterQual procedural criteria. Geographic scope: Applies only to the state of Kansas. InterQual procedural criteria are the primary clinical source for medical necessity determinations. Effective date: August 1, 2025. Last review date: August 1, 2025.

Medical-Necessity Criteria

General Coverage Determination

Surgery of the hip and surgical treatment for Femoroacetabular Impingement (FAI) Syndrome is proven and medically necessary in certain circumstances. For medical necessity clinical coverage criteria, refer to the InterQual CP for the listed procedures.

State limitation: Applies only to the state of Kansas
InterQual procedural criteria required: Coverage for specific hip surgical procedures is determined by meeting InterQual Procedural Criteria for the relevant procedure (Arthroscopy diagnostic +/- synovial biopsy hip; Arthroscopy surgical hip; Arthrotomy hip; Removal and replacement; Total joint replacement hip; Hemiarthroplasty hip)
Medical records documentation may be required to assess whether the member meets clinical criteria; documentation does not guarantee coverage

Referenced Procedure / HCPCS Codes

Referenced CPT / Procedure Codes (for InterQual-specified procedures)CPT

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	Arthrotomy, hip
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

1–10 of 16

1/2

Referenced HCPCS / Other CodesHCPCS

S2118

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

Provider Actions & Documentation Requirements

Documentation Required

Use InterQual criteria for medical necessity

Refer to and document compliance with the applicable InterQual clinical procedural (CP) criteria for the specific hip procedure requested to support medical necessity determinations. Ensure the chart notes, operative reports, imaging, and PROMs cited in the InterQual criteria are included in the medical record for review.

Affected procedures/CPT groups: Arthroscopy (diagnostic ± synovial biopsy) hip (29860); Arthroscopy, surgical, hip (29861, 29862, 29863, 29914, 29915, 29916, 29999); Arthrotomy, hip (27120); Hemiarthroplasty, hip (27125); Total hip arthroplasty and revisions/conversions (27130, 27132, 27134, 27137, 27138); Unlisted pelvis/hip procedure (27299); HCPCS S2118

Documentation Required

Medical records documentation may be required

Medical records documentation may be requested to assess whether the member meets the clinical criteria for coverage. Submission of documentation is required to support review but does not guarantee that the services requested will be covered.

Benefit coverage is determined by federal, state, or contractual requirements and applicable laws; documentation must align with those requirements. This policy and the documentation requirement apply only to the state of Kansas.

Background & Definitions

Purpose: This policy summarizes the coverage rationale for hip surgery, including treatment of Femoroacetabular Impingement (FAI) Syndrome. It defines clinical terms and outcome measures (WOMAC, HOOS, iHOT-33), describes FAI subtypes (Cam, Pincer, Combined) with radiographic thresholds (e.g., alpha angle > 50 degrees for Cam; LCEA > 40 degrees, coxa profunda, or acetabular retroversion for Pincer), and reports cartilage grading (Outerbridge Grades I–IV) and radiographic osteoarthritis classifications (Kellgren-Lawrence, Tonnis). FDA information is included for informational purposes only and FDA approval alone is not a basis for coverage. For specific medical necessity clinical coverage criteria, InterQual criteria are the primary clinical source and must be referenced for the listed procedures.

Term	Definition
Outerbridge	Classification of chondral lesions Grade 0–IV: Grade 0: Normal; Grade I: Cartilage with softening and swelling; Grade II: Partial-thickness defect with fissures on the surface that do not reach subchondral bone or exceed 1.5 cm in diameter; Grade III: Fissuring to the level of subchondral bone in an area with a diameter more than 1.5 cm; Grade IV: Exposed subchondral bone
WOMAC	Western Ontario and McMaster Universities Arthritis Index (WOMAC): disease-specific, self-administered questionnaire composed of 24 items grouped into three dimensions: pain, stiffness, and physical function; used to evaluate patients with hip (and knee) osteoarthritis. Thresholds used in policy: Disabling Pain = WOMAC domain > 40; Functional Disability = WOMAC functional limitation domain >= 40
HOOS	Hip Dysfunction and Osteoarthritis Outcome Score (HOOS): a self-administered hip-specific questionnaire of 43 items in five subscales (pain, symptoms, function in daily living, function in sport and recreation, and hip-related quality of life) to evaluate symptoms and functional limitations
iHOT-33	International Hip Outcome Tool (iHOT-33): a PROM for people with hip disorders including FAI; consists of four subscales (symptoms and functional limitations 16 items, sports/recreational physical activity 6 items, job-related concerns 4 items, social/emotional/lifestyle concerns) with items scored 0–100 and final score the sum divided by 33
Femoroacetabular Impingement (FAI) Syndrome	Hip abnormal formation or bone overgrowth causing abnormal contact, labral tears, and cartilage breakdown; includes three types — Cam (loss of sphericity of femoral head; alpha angle > 50 degrees), Pincer (overcoverage of femoral head; lateral center edge angle > 40 degrees, coxa profunda, or acetabular retroversion), and Combined (both types present)