Surgery of the Hip (for Tennessee Only)
Policy governing medical necessity and coverage criteria for surgical procedures of the hip for Tennessee Medicaid and CoverKids members, including arthroscopy for Femoroacetabular Impingement (FAI) and total hip replacement procedures.
Revised description for CPT codes 27299 and 29999 and added notation that iliopsoas tendon release, capsular repair, and capsular release are considered integral to the primary hip procedure and not separately reimbursable.
Updated definition of 'Radiographic Findings of Osteoarthritis'.
Archived previous policy version CS056TN.W.
Coverage Criteria for Hip Surgery
Medical necessity tied to InterQual criteria
Covered when InterQual CP procedure criteria are met; exceptions and not medically necessary conditions follow.
Refer to InterQual CP: Arthroscopy (diagnostic and surgical), Arthrotomy, Hemiarthroplasty, Removal and Replacement TJR, and Total Joint Replacement (TJR) hip procedures.
FAI — Not Medically Necessary Criteria
Not medically necessary when the following are present for FAI surgical treatment:
Surgical treatment for FAI in these contexts is considered unproven and not medically necessary.
Evidence-based coverage considerations
Clinical evidence summarized for surgical versus nonoperative management of FAI — findings relevant to coverage decisions
Reported follow-up intervals include 6, 8, 12, and 24 months; magnitude and significance vary by outcome and study.
Consider OA severity (Tönnis and radiographic findings) when determining appropriateness of arthroscopy.
Caution is advised in extrapolating short-term improvements to long-term joint preservation; future research should address MCID, PASS, and longer-term outcomes.
Surgical treatment for Femoroacetabular Impingement (FAI) Syndrome is considered medically necessary only when the applicable InterQual® procedural criteria are met for diagnostic or surgical hip arthroscopy, arthrotomy, or arthroplasty. When assessing appropriateness, document clinical symptoms, objective functional limitation, prior conservative management, and imaging graded by accepted systems (Tönnis, Outerbridge). Conversely, surgical treatment for FAI is unproven and not medically necessary in the presence of advanced osteoarthritis (Tönnis Grade 2 or 3) or severe cartilage damage (Outerbridge Grade III or IV), which are exclusionary thresholds for arthroscopic FAI procedures.
Certain procedures performed incident to a primary hip operation are considered integral components of that procedure and are not separately reimbursable. The policy explicitly notes that iliopsoas tendon release, capsular repair, and capsular release are integral to the primary hip procedure and therefore should not be billed separately; debridement performed during hip arthroscopy for FAI CPT codes 29914, 29915, and 29916 is likewise considered integral and not separately reimbursable.
Arthroscopic surgical management of FAI is not medically necessary for members with radiographic evidence of advanced osteoarthritis or severe chondral injury. Specifically, the policy states that FAI surgery is unproven and not medically necessary when Tönnis Grade is 2 or 3 or when cartilage damage is Outerbridge Grade III or IV.
Clinical evidence indicates that the presence of radiographic osteoarthritis is associated with worse outcomes after arthroscopic treatment for FAI. A meta-analysis (Lei et al., 2019) found significantly higher overall failure rates and a higher rate of conversion to total hip arthroplasty when OA was present—pooled conversion was 37.3% with OA versus 9.7% without—supporting the policy position that advanced radiographic OA predicts poorer surgical outcomes and higher likelihood of subsequent THA.
Applicable Codes and Coding Guidance
| 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) |
| 27299 | Unlisted procedure, pelvis, or hip joint |
| 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 |
| 29999 | Unlisted procedure, arthroscopy |
| 27125 | Hemiarthroplasty, hip, partial (e.g., femoral stem prosthesis, bipolar arthroplasty) |
| 27130 | Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty) |
| 27132 | Conversion of previous hip surgery to total hip arthroplasty |
| S2118 | Metal-on-metal total hip resurfacing, including acetabular and femoral components |
Provider Requirements and Actions
Prior authorization required; submit records and imaging
Prior authorization/clinical review is required for the listed hip procedure codes; submit supporting medical records and imaging that meet the policy's documentation requirements at time of review. Include the applicable CPT/HCPCS codes referenced in the policy when requesting authorization.
- Submit complete medical notes and imaging per policy (see documentation requirements).
- Include the procedure CPT/HCPCS codes listed in the Applicable Codes section when requesting prior authorization.
Coding clarifications and policy revisions for unlisted codes
Policy updates clarify coding descriptions for CPT 27299 and 29999 and note that certain procedures are integral to the primary hip procedure and are not separately reimbursable; verify plan-specific prior authorization and reimbursement rules when coding or billing.
Use InterQual CP procedures for medical necessity determinations
InterQual® Clinical Practice (CP) procedure criteria are used as the medical necessity reference for multiple hip procedures; determinations should reference the listed InterQual CP procedures.
- InterQual CP procedures referenced include diagnostic/surgical hip arthroscopy, arthrotomy, hemiarthroplasty, removal/replacement TJR, and total hip replacement.
Document conservative therapy trials prior to surgery when appropriate
Consider and document trials of conservative management prior to surgical intervention when appropriate; evidence comparisons reference physiotherapy, activity modification, and injections as nonoperative options.
- Conservative options referenced include physiotherapy, activity modification, and injections.
- Document prior nonoperative therapies tried, dates, and reasons for discontinuation in the medical record.
Required documentation: imaging interpretation, impressions, interpreter specialty, and supporting records
Provide complete imaging interpretation and labeled diagnostic images when requested, plus supporting clinical records that document the condition, severity, prior therapies, and treatment plan for review.
- Include complete diagnostic imaging interpretation with impression and the interpreter's specialty.
- For FAI (CPT 29914–29916), include radiographic reports using Tönnis or Outerbridge grading and, when requested, labeled images with date and member identifiers submitted via the external portal (faxes not accepted).
- Include severity of pain/functional disability (WOMAC or HOOS), prior therapies tried/failed with dates and reasons, pertinent joint exam, comorbidities, and physician's treatment plan.
Document plan-specific coverage determinations and use of third‑party tools
When documenting coverage decisions, reference applicable federal, state, or contractual benefit plan requirements and record how the requested procedure meets plan criteria and any third‑party tools used in the determination (e.g., InterQual).
- Document which federal/state/contractual requirements govern if they differ from the standard policy.
- Record that InterQual or other third‑party tools were used and how the case meets those criteria.
Denial risk: FAI surgery not medically necessary with advanced OA or severe cartilage damage
Do not approve or bill arthroscopic FAI surgery for patients with advanced osteoarthritis (Tönnis Grade 2 or 3) or severe cartilage damage (Outerbridge Grade III or IV); these conditions are listed as not medically necessary and typically lead to denial.
- Presence of Tönnis Grade ≥2 or Outerbridge Grade ≥III is a denial trigger for FAI surgical treatment per the policy.
- Advanced radiographic OA is associated with higher failure and conversion to total hip arthroplasty and may not meet medical necessity for arthroscopy.
Integral procedures are not separately reimbursable—billing may trigger denial
Iliopsoas tendon release, capsular repair, and capsular release (and debridement when performed with FAI arthroscopy CPT codes 29914–29916) are considered integral to the primary hip procedure and are not separately reimbursable; separate billing of these components may result in denial.
- Debridement during hip arthroscopy is integral to FAI surgery CPT codes 29914, 29915, and 29916 and not separately reimbursable.
- Iliopsoas tendon release, capsular repair, and capsular release are considered integral to the primary hip procedure and should not be billed as separate reimbursable procedures.
Clinical Background
Femoroacetabular impingement (FAI) results from abnormal hip morphology or bone overgrowth that causes repetitive contact between the proximal femur and acetabulum. The three common morphologies are cam (femoral asphericity), pincer (acetabular overcoverage), and combined types; each can produce labral tears and progressive chondral damage. Clinically, FAI presents with activity-related groin pain, reduced internal rotation, and impaired function. Radiographic measurements (for example, lateral center edge angle, alpha angle) and grading systems (Tönnis for osteoarthritis, Outerbridge for cartilage damage) are used to quantify disease severity and guide treatment decisions. Advanced osteoarthritis or severe cartilage lesions are associated with inferior outcomes after arthroscopic correction and a greater likelihood of conversion to total hip arthroplasty.
Definitions and Grading Systems
Policy Revision History
Updated definition of 'Radiographic Findings of Osteoarthritis'; revised descriptions for CPT 27299 and 29999; clarified that iliopsoas tendon release, capsular repair/release, and debridement during hip arthroscopy (CPT 29914, 29915, 29916) are considered integral to the primary hip procedure and not separately reimbursable.
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