Surgery of the Hip

Coverage Summary

Defines UnitedHealthcare coverage rationale and medical necessity references for hip surgical procedures including arthroscopy, arthrotomy, hemiarthroplasty, and total hip arthroplasty. Coverage decisions are determined by meeting the InterQual CP criteria for the specific procedure. Policy Number: SRST2026T0503KK. Effective Date: 2026-05-01. Coverage stance: mixed (procedural coverage with criteria; some exclusions apply).

Key thresholds / quick facts

Tönnis Grade exclusionGrade 2 or 3 = advanced osteoarthritis (FAI surgery NOT medically necessary)

Outerbridge Grade exclusionGrade III or IV = severe cartilage damage (FAI surgery NOT medically necessary)

WOMAC Pain threshold (Disabling Pain)WOMAC pain domain > 40

WOMAC Function threshold (Functional Disability)WOMAC functional limitation domain > 40

Alpha angle (Cam-type radiographic criterion)Alpha angle > 50 degrees indicates cam morphology

Lateral center edge angle (Pincer-type radiographic criterion)Lateral center edge angle > 40 degrees indicates pincer morphology

Radiographic finding rule for severe OAThree or more moderate-to-severe radiographic findings (eg, joint space narrowing, osteophytes, subchondral sclerosis/cysts, deformity) accepted to support diagnosis of severe osteoarthritis

Medical-Necessity Criteria

General Coverage Rationale

Surgery of the hip and surgical treatment for FAI Syndrome is proven and medically necessary in certain circumstances. For medical necessity clinical coverage criteria, refer to the InterQual CP listed below. Provider must refer to InterQual CP for medical necessity detail.

InterQual-based coverage determination: Coverage determined by meeting 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 TJR hip, Total joint replacement hip).

Provider must refer to InterQual CP for medical necessity detail.

Femoroacetabular Impingement (FAI) Surgical Treatment - Exclusion

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

Exclusion criteria for FAI surgery: Advanced osteoarthritis defined as Tönnis Grade 2 or 3.Tönnis Grade 2 or 3

Applicable Codes

Femoroacetabular Impingement (FAI) Syndrome - Arthroscopic Procedure CodesCPTCovered

29914	Arthroscopy, hip, surgical; with femoroplasty (treatment of cam lesion)
29915	Arthroscopy, hip, surgical; with acetabuloplasty (treatment of pincer lesion)
29916	Arthroscopy, hip, surgical; with labral repair

Arthroscopy, Surgical, Hip (referenced CPTs)CPTCovered

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

Arthroscopy, Diagnostic, +/- Synovial Biopsy, Hip (referenced CPTs)CPTCovered

29860

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

Arthrotomy, HipCPTCovered

27120

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

Hemiarthroplasty, HipCPTCovered

27125

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

Removal and Replacement, Total Joint Replacement (TJR), HipCPTCovered

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

Removed / Not separately reimbursable / Deleted codes from this policy versionCPT|HCPCSNot Covered

27299	Unlisted procedure, femur (removed from policy applicable codes)
29999	Unlisted procedure, arthroscopy (removed from policy applicable codes)
S2118	HCPCS code S2118 (removed from policy applicable codes)

Provider Actions

Documentation Required

Use InterQual CP for medical necessity determination

Providers must refer to and meet the InterQual® CP criteria for the specified hip procedures to establish medical necessity; coverage decisions are determined by the InterQual CP procedures listed in the policy (e.g., arthroscopy diagnostic +/- synovial biopsy, arthroscopy surgical hip, arthrotomy hip, hemiarthroplasty hip, removal and replacement TJR hip, total joint replacement hip).

Billing Rule

Certain procedures/components considered integral and not separately reimbursable

Iliopsoas tendon release, capsular repair or release, and debridement performed during hip arthroscopy are considered integral to the primary hip procedure and are not separately reimbursable when reported with the FAI arthroscopy codes listed below.

29914
29915

Background, Evidence & Definitions

UnitedHealthcare references the InterQual CP criteria for determinations of medical necessity for hip surgeries and FAI procedures. Femoroacetabular impingement (FAI) is defined as abnormal contact between the femoral head and acetabulum due to bone morphology and includes three types: pincer (acetabular overcoverage; lateral center edge angle > 40 degrees), cam (loss of femoral head sphericity; alpha angle > 50 degrees), and combined (mixed) when both are present. Radiographic measures and patient-reported outcome measures (PROMs such as HOOS and iHOT-33) are used to assess severity and outcomes. The policy excludes surgical treatment for FAI when there is advanced osteoarthritis (Tönnis Grade 2 or 3) and/or severe cartilage damage (Outerbridge Grade III or IV), because these predict poorer outcomes and higher rates of conversion to total hip arthroplasty.

Evidence / Finding	Result/Value
Migliorini et al. (2025) systematic review of long-term arthroscopic management for FAI
32% required total hip arthroplasty (THA) within ten years
FAIT randomized controlled trial (Palmer et al., 2025) — 3-year outcomes
HOS ADL higher in arthroscopy group; mean difference 8.9 (95% CI 7.0, 10.8) and SHOMRI score lower (difference -15.94; 95% CI -18.69, -13.19)
Meta-analysis by Lei et al. (2019) on prognostic impact of osteoarthritis in FAI surgery
Conversion to THA higher with OA: 37.3% in FAI with OA vs 9.7% in FAI alone; higher overall failure rate with OA
Systematic reviews and RCT syntheses (Gohal 2019; Mok 2021; Kim 2021) — PROMs and HRQL improvements after arthroscopy compared with conservative care
Improvements reported in iHOT-33, HOOS, EQ-5D and other hip-specific HRQL measures at 12–24 months; some RCT meta-analyses show superior ADL and quality-of-life outcomes for arthroscopy
Caveats from FAIT and other trials
No difference in radiographic minimum joint space width (mJSW) at 38 months; interpret with caution due to midterm follow-up and loss to follow-up

Definitions

Disabling PainWOMAC pain domain > 40

Functional DisabilityWOMAC functional limitation domain > 40

Femoroacetabular Impingement (FAI) SyndromeAbnormal contact between femoral head and acetabulum due to bone morphology (pincer, cam, or combined) leading to labral tears and cartilage breakdown

Revision History

2026-05-01material_revisionLatest

Applicable Codes updated; CPT/HCPCS codes 27299, 29999, and S2118 removed. Also removed 'Medical Records Documentation Used for Reviews' section and archived previous policy version 2026T0503JJ.

2026-05-01non-material_clarification

Supporting information updated.