CurrentUnitedHealthcarePolicy CS056NE.Z

Surgery of the Hip (for Nebraska Only)

UnitedHealthcare medical policy (Nebraska only) governing coverage and documentation requirements for hip surgeries including arthroscopy, arthrotomy, hemiarthroplasty, total joint replacement, and surgical treatment of Femoroacetabular Impingement (FAI) Syndrome; references InterQual CP procedure criteria for medical necessity and specifies when FAI surgery is not medically necessary.

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Hip (for Nebraska Only)

Policy CodePolicy CS056NE.Z

Change TypeRevised applicable code descriptions; updated clinical evidence/references

Effective DateMarch 1, 2026

Next Review Date

Key ActionInclude complete diagnostic imaging interpretation and, for FAI, Tönnis or Outerbridge grading and submit labeled images via the external portal when requested.

POLICY UPDATE CHANGES

Applicable Codes: Revised description for CPT codes 27299 and 29999.

1State-specific policy (Nebraska)

3FAI CPT codes highlighted (29914-29916)

2Not medically necessary criteria (Tönnis, Outerbridge)

Coverage Summary

Scope: UnitedHealthcare medical policy for Nebraska only addressing surgery of the hip, including arthroscopy, arthrotomy, hemiarthroplasty, total joint replacement, and surgical treatment of Femoroacetabular Impingement (FAI) Syndrome. Payer/location: UnitedHealthcare - Nebraska. Policy number: CS056NE.Z. Effective date: 2026-03-01.

Coverage stance: Mixed — the policy defers to InterQual® CP procedural criteria for detailed medical necessity determinations for hip procedures and states that surgical treatment for FAI is medically necessary in certain circumstances but is not medically necessary when advanced osteoarthritis or severe cartilage damage is present.

High-level summary: Coverage determinations rely on InterQual CP: Procedures for procedure-specific medical necessity (including diagnostic and surgical hip arthroscopy, arthrotomy, hemiarthroplasty, and total joint replacement). Surgical treatment for FAI is considered proven and medically necessary in specified situations per InterQual, but is excluded when there is advanced osteoarthritis (Tönnis Grade 2 or 3) and/or severe cartilage damage (Outerbridge Grade III or IV).

General Coverage Rationale

Surgery of the hip and surgical treatment for FAI Syndrome is proven and medically necessary in certain circumstances as defined by InterQual CP procedure criteria:

Member meets InterQual CP criteria for the specific procedure (Arthroscopy diagnostic +/- synovial biopsy; 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: Procedures for detailed medical necessity criteria.

Not Medically Necessary / Exclusions for FAI Surgical Treatment

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

Exclusions - Not Medically Necessary: Advanced osteoarthritis defined as Tönnis Grade 2 or 3.Tönnis Grade 2 or 3

Exclusions - Not Medically Necessary: Severe cartilage damage defined as Outerbridge Grade III or IV.Outerbridge Grade III or IV

Inpatient Stay Justification

If an inpatient stay is requested, documentation must support at least one of the following:

Inpatient Justification: Surgery is bilateral.

Inpatient Justification: Member has significant comorbidities; include list and current treatment.

Inpatient Justification: Member lacks appropriate resources to support post-operative outpatient care; include barriers to outpatient care.

Documentation Requirements (Medical Records Used for Reviews)

Medical records must document ALL applicable items; inclusion may be required to assess clinical criteria for coverage:

Documentation Requirements: Complete diagnostic interpretation of imaging findings including relevant clinical information, detailed report of imaging findings, and impression.

Documentation Requirements: Specialty(ies) of the provider(s) who interpreted the images.

Documentation Requirements for FAI CPTs: For FAI (CPT 29914, 29915, 29916): radiographic reports of presence and severity of cartilage damage using Tönnis or Outerbridge grading.Tönnis or Outerbridge grading

Image Submission: Upon request, submission of specific diagnostic images (MRI, CT, X-ray, bone scan) labeled with date and case/member identifiers; submit via external portal (www.uhcprovider.com/paan); faxes not accepted.

Documentation Requirements: Condition requiring procedure.

Documentation Requirements: Severity of pain and details of functional disability interfering with ADLs using a standard scale (e.g., WOMAC or HOOS).WOMAC or HOOS; WOMAC domains > 40 define disabling/functional disability

Documentation Requirements: Physician's treatment plan, including pre-op discussion.

Documentation Requirements: Pertinent physical examination of the relevant joint.

Documentation Requirements: Comorbid medical conditions (cardiovascular, hypertension, diabetes, cancer, pulmonary, neurodegenerative).

Documentation Requirements: Prior therapies/treatments tried, failed, or contraindicated with dates and reasons for discontinuation.

Documentation Requirements: Date of failed previous hip fracture fixation, if applicable.

Referenced Codes

Referenced CPT / Procedure Codes (informational; listing does not guarantee coverage)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	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

1–10 of 16

1/2

Other HCPCS / Device CodesHCPCS

S2118

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

Provider Actions & Prior Authorization

Prior Authorization

InterQual CP criteria required for medical necessity determination

Coverage determinations rely on InterQual® CP procedural criteria. Providers must document that the member meets the applicable InterQual criteria for the specific hip procedure requested to support medical necessity.

Documentation Required

Submit imaging reports and images when requested

When requested, submit complete diagnostic imaging reports and, if asked, the labeled diagnostic images via the external portal. Do not send images by fax.

Affected CPT codes: 29914, 29915, 29916
Include a complete diagnostic interpretation: detailed findings, impression, and specialty(ies) of the interpreting provider(s).
For FAI (CPT 29914, 29915, 29916) include radiographic grading of cartilage damage using Tönnis or Outerbridge.
When images are requested, submit labeled diagnostic image(s) (date and case/member identifiers) via the external portal at www.uhcprovider.com/paan; faxes will not be accepted.

Documentation Required

Preauthorization inpatient justification

If an inpatient admission is being requested, medical records must document justification for inpatient care. Provide documentation that at least one of the following applies: the surgery is bilateral; the member has significant comorbidities (include the list of comorbidities and current treatment); or the member lacks appropriate resources for post‑operative outpatient care (describe barriers).

Denial Risk

FAI surgery exclusion for advanced OA or severe cartilage damage

Claims for surgical treatment of Femoroacetabular Impingement (FAI) may be considered not medically necessary and denied when advanced osteoarthritis or severe cartilage damage is present.

Affected CPT codes: 29914, 29915, 29916
Not medically necessary when Tönnis Grade 2 or 3 osteoarthritis is present.
Not medically necessary when Outerbridge Grade III or IV cartilage damage is present.

Background, Evidence & Definitions

Background: This policy references and defers to InterQual® CP: Procedures to determine medical necessity for a range of hip surgeries (diagnostic and surgical hip arthroscopy, arthrotomy, hemiarthroplasty, and total joint replacement).

Evidence summary: Clinical studies and systematic reviews indicate that arthroscopic treatment for FAI can improve patient-reported outcomes versus conservative care for many patients, but outcomes are worse and failure rates higher when preoperative osteoarthritis or advanced articular cartilage disease are present. Specific findings include higher long-term conversion to total hip arthroplasty (e.g., roughly 32% requiring THA within ten years in a long-term systematic review) and meta-analytic evidence that radiographic OA is correlated with higher failure rates and increased conversion to THA. Randomized trials (e.g., FAIT) show improved pain and function and less MRI-measured cartilage damage with arthroscopy versus physiotherapy at midterm follow-up, but no radiographic difference in joint-space narrowing and the results require cautious interpretation due to follow-up limitations. These data underscore the need for careful patient selection when considering hip arthroscopy for FAI, particularly avoidance of surgery in the presence of Tönnis Grade 2 or 3 osteoarthritis or Outerbridge Grade III or IV cartilage damage.

Study / Evidence	Finding
Migliorini et al. (2025) — systematic review of arthroscopic management for FAI with >10-year follow-up	32% of patients required conversion to total hip arthroplasty within 10 years
Palmer et al. (2025) — FAIT randomized controlled trial, 38‑month follow-up	Arthroscopy produced higher HOS ADL and lower SHOMRI scores versus physiotherapy; no difference in minimum joint space width (mJSW) at 38 months

Definitions

Disabling PainWOMAC pain domain > 40 (Western Ontario and McMaster Universities Arthritis Index)

Femoroacetabular Impingement (FAI) SyndromeAbnormal contact due to hip formation or bone overgrowth (pincer, cam, or combined) causing labral tears and cartilage breakdown; includes pincer (overcoverage: lateral center edge angle > 40°, coxa profunda, or acetabular retroversion), cam (loss of femoral head sphericity or alpha angle > 50°), or combined types

Functional DisabilityWOMAC functional limitation domain > 40 (Western Ontario and McMaster Universities Arthritis Index)

Thresholds

WOMAC Pain Domain Threshold> 40

WOMAC Functional Domain Threshold> 40

Outerbridge Grade (severe cartilage damage)Grade III or IV

Tönnis Grade (advanced osteoarthritis)Grade 2 or 3

Radiographic Pincer ExamplesLateral center edge angle > 40 degrees; coxa profunda; acetabular retroversion

Radiographic Cam ExampleAlpha angle > 50 degrees (loss of femoral head sphericity / bony prominence)