CurrentUnitedHealthcarePolicy CS056.AA

Surgery Hip Cs

UnitedHealthcare medical policy CS056.AA governing coverage and medical necessity of hip surgeries including arthroscopy, arthrotomy, hemiarthroplasty, and total hip replacement, and surgical treatment for Femoroacetabular Impingement (FAI) Syndrome; references InterQual criteria for detailed clinical coverage conditions and lists applicable CPT/HCPCS codes and definitions.

Policy Summary

PayerUnitedHealthcare

PolicySurgery Hip Cs

Policy CodePolicy CS056.AA

Change TypeRevised definitions; added billing clarification; removed state-specific language

Effective DateApr 1, 2026

Next Review Date

Key ActionProviders must supply medical records documentation to support that the member meets InterQual clinical criteria and applicable federal/state/contractual benefit requirements; documentation may be required for review and coverage is not guaranteed by submission.

SourceLink

POLICY UPDATE CHANGES

Added notation that iliopsoas tendon release, capsular repair, and capsular release surgery are integral to the primary hip procedure and not separately reimbursable; debridement during hip arthroscopy is integral to CPT codes 29914, 29915, and 29916 and not separately reimbursable.

Updated definition of 'Radiographic Findings of Osteoarthritis'.

Removed content/language pertaining to the state of Louisiana.

Updated Clinical Evidence and References sections to reflect the most current information.

7InterQual procedure criteria referenced

3FAI-related arthroscopy CPT codes (listed)

2Radiographic grading systems defined (Tönnis, Outerbridge)

Coverage Summary

This policy (Policy Number CS056.AA) is CURRENT and effective April 1, 2026 (last reviewed April 1, 2026). It governs coverage and medical necessity determinations for surgery of the hip, including arthroscopy, arthrotomy, hemiarthroplasty, total hip replacement, and surgical treatment for Femoroacetabular Impingement (FAI) Syndrome, and lists applicable CPT/HCPCS codes. For specific procedure-level medical necessity determinations, UnitedHealthcare references the InterQual® CP criteria (e.g., Arthroscopy, Diagnostic +/- Synovial Biopsy, Arthroscopy, Surgical, Hip; Arthrotomy; Hemiarthroplasty; Total Joint Replacement). Evidence summarized in the policy indicates that hip arthroscopy can improve patient-reported outcome measures (PROMs) in selected patients, but outcomes are worse when advanced osteoarthritis or severe cartilage damage are present (higher failure and conversion-to-THA rates).

Key thresholds and quick facts

WOMAC pain thresholdWOMAC pain domain > 40

WOMAC functional thresholdWOMAC functional limitation domain > 40

Alpha angle (cam) threshold> 50 degrees

Lateral center edge angle (pincer) threshold> 40 degrees

Radiographic severe OA criteriaThree or more moderate to severe radiographic findings (e.g., joint space narrowing, osteophytes, subchondral sclerosis/cysts, deformity) accepted as severe OA

Tönnis grade exclusionTönnis Grade 2 or 3 = advanced osteoarthritis (exclusion for FAI surgery)

Outerbridge grade exclusionOuterbridge Grade III or IV = severe cartilage damage (exclusion for FAI surgery)

InterQual procedure criteria referenced7

FAI-related arthroscopy CPT codes listed29914, 29915, 29916 (3 codes)

Radiographic grading systems definedTönnis and Outerbridge (2 systems)

Medical Necessity Criteria

General Coverage Statement

This policy defines when hip surgeries, including FAI surgical treatments, are considered medically necessary and references InterQual CP for specific procedure criteria.

Medical necessity determined by InterQual CP criteria for the following procedures: Arthroscopy, Diagnostic +/- Synovial Biopsy, Hip; Arthroscopy, Surgical, Hip; Arthroscopy, Surgical, Hip (Pediatric); Arthrotomy, Hip; Hemiarthroplasty, Hip; Removal and Replacement, Total Joint Replacement (TJR), Hip; Total Joint Replacement (TJR), Hip.

Refer to InterQual CP for detailed clinical coverage criteria

FAI Syndrome — Exclusion for Advanced OA / Severe Cartilage Damage

Surgical treatment for FAI is unproven and not medically necessary when advanced degenerative changes are present; grading definitions are provided in this policy.

Presence of advanced osteoarthritis defined as Tönnis Grade 2 or 3Tönnis Grade 2 or 3

Tönnis Classification defined in policy

Provider Actions & Billing Rules

Documentation Required

Submit medical records to demonstrate InterQual criteria

Providers must supply medical records documentation to support that the member meets InterQual clinical criteria and applicable federal/state/contractual benefit requirements; documentation may be required for review and submission does not guarantee coverage.

Billing Rule

Integral procedures not separately reimbursable

Iliopsoas tendon release, capsular repair, and capsular release surgeries are considered integral to the primary hip procedure and are not separately reimbursable. Debridement during hip arthroscopy is considered integral to the FAI surgery CPT codes 29914, 29915, and 29916 and therefore is not separately reimbursable.

Affected CPT codes: 29914, 29915, 29916
Note: This change impacts billing/reimbursement for ancillary procedures (those listed above are not separately reimbursable).

Coding

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

29860

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

Arthroscopy, Surgical, Hip (reference)CPT

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

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)

Total Joint Replacement (TJR), Hip / Removal and Replacement / RevisionCPT

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

FAI-specific Arthroscopy / Unlisted FAI ProceduresCPT

27299	Unlisted procedure, pelvis or hip joint (i.e., capsular plication, gluteal tendon repair)
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 (i.e., capsular plication, gluteal tendon repair)

Other HCPCSHCPCS

S2118

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

Background, Evidence, and Definitions

This policy defines when hip surgeries, including FAI surgical treatments, are considered medically necessary and directs users to InterQual® CP for detailed clinical coverage criteria for specific procedures. It explains that surgical treatment for FAI is proven and medically necessary in certain circumstances, but is unproven and not medically necessary in the presence of advanced osteoarthritis (Tönnis Grade 2 or 3) and/or severe cartilage damage (Outerbridge Grade III or IV). The clinical evidence cited includes randomized trials and multiple meta-analyses showing that arthroscopy can provide superior PROMs versus conservative care in selected patients (e.g., FAIT RCT showing an 8.9-point higher HOS ADL at 38 months in the arthroscopy group and systematic reviews/meta-analyses reporting PROM improvements), while systematic reviews and meta-analyses also report higher failure and conversion-to-total-hip-arthroplasty rates when radiographic osteoarthritis is present. The policy also notes billing guidance that certain ancillary procedures (iliopsoas tendon release, capsular repair, capsular release) and debridement during hip arthroscopy are considered integral to the primary hip procedure and are not separately reimbursable.

Evidence Item	Summary/Value
Long-term arthroscopy outcomes requiring THA	Up to 32% of patients required total hip arthroplasty within ten years (Migliorini et al., 2025).
RCT FAIT 3-year HOS ADL difference	Hip Outcome Score ADL higher in arthroscopy group by 8.9 points (95% CI 7.0 to 10.8) at ~38 months (Palmer et al., 2025).
Meta-analyses summary	Multiple meta-analyses and RCTs report arthroscopy can provide superior patient‑reported outcome measures versus conservative therapy in selected patients; evidence limited by heterogeneity and follow‑up duration.

Definitions

Disabling Pain (term)WOMAC pain domain > 40

Femoroacetabular Impingement (FAI) Syndrome (term)Abnormal contact between femoral head and acetabulum due to bony morphology (pincer, cam, or combined) causing labral tears and cartilage breakdown; radiographic examples: LCEA > 40° for pincer, alpha angle > 50° for cam

Revision History

04/01/2026revised

Updated definition of 'Radiographic Findings of Osteoarthritis'.

04/01/2026added

04/01/2026removed

Removed content/language pertaining to the state of Louisiana.