CurrentUnitedHealthcarePolicy CS056NM.F

Surgery Hip Nm Cs

UnitedHealthcare New Mexico medical policy defining medical necessity criteria for hip surgeries including arthroscopy, arthrotomy, hemiarthroplasty, and total hip replacement, with specific guidance on Femoroacetabular Impingement (FAI) Syndrome and documentation/billing integration rules.

Policy Summary

PayerUnitedHealthcare

PolicySurgery Hip Nm Cs

Policy CodePolicy CS056NM.F

Change TypeDefinitionsApplicable CodesFAI CPT descriptions revisedBilling clarification

Effective DateMay 1, 2026

Next Review Date

Key ActionFor FAI CPT codes 29914/29915/29916 include radiographic reports with Tönnis or Outerbridge grading; labeled diagnostic images must be submitted via the external portal (www.uhcprovider.com/paan); faxes not accepted.

SourceLink

POLICY UPDATE CHANGES

Updated description for CPT codes 27299 and 29999 in Femoroacetabular Impingement (FAI) Syndrome section.

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

Updated definition of 'Radiographic Findings of Osteoarthritis'.

Archived previous policy version CS056NM.E.

3FAI arthroscopy CPT codes highlighted as integral debridement

2Exclusion thresholds defined (Tönnis, Outerbridge)

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Coverage Summary

UnitedHealthcare New Mexico medical policy (CS056NM.F) provides state-specific coverage criteria for surgical procedures of the hip, including arthroscopy, arthrotomy, hemiarthroplasty, and total hip replacement, and offers specific guidance for Femoroacetabular Impingement (FAI) Syndrome and related documentation and billing integration rules.

Key thresholds and quick facts

WOMAC Pain cutoff> 40 (Disabling Pain)

WOMAC Functional cutoff> 40 (Functional Disability)

Tönnis exclusion thresholdGrade 2 or 3 = Advanced osteoarthritis (FAI surgery NOT medically necessary)

Outerbridge exclusion thresholdGrade III or IV = Severe cartilage damage (FAI surgery NOT medically necessary)

Radiographic rule for severe OAThree or more moderate to severe radiographic findings accepted as sufficient for severe osteoarthritis

FAI arthroscopy debridement billing noteDebridement during hip arthroscopy is considered integral to FAI surgery codes 29914/29915/29916 and not separately reimbursable

Medical-Necessity Criteria

General Coverage Rationale

Surgery of the hip is proven and medically necessary in certain circumstances; refer to InterQual CP procedures for specific medical necessity criteria:

InterQual and Benefit Note

InterQual Procedures: Coverage follows InterQual CP: Procedures for Arthroscopy (diagnostic +/- synovial biopsy), Arthroscopy Surgical Hip, Arthroscopy Surgical Hip (Pediatric), Arthrotomy Hip, Hemiarthroplasty Hip, Removal and Replacement TJR Hip, Total Joint Replacement Hip
Refer to InterQual criteria for detailed clinical necessity requirements.
Benefit/Contractual Determination: Benefit coverage determined by federal, state, or contractual requirements; medical records documentation may be required to assess clinical criteria
Medical records documentation may be requested during review and does not guarantee coverage.

Femoroacetabular Impingement (FAI) Syndrome - Not Medically Necessary Conditions

Provider Actions & Operational Notes

Documentation Required

Submit imaging reports and graded cartilage assessments for FAI

For FAI CPT codes 29914, 29915, and 29916, submit complete diagnostic imaging reports that include Tönnis or Outerbridge cartilage grading. When requested, specific diagnostic images (MRI, CT, X-ray, bone scan) must be labeled with date and case number or member name/ID and submitted via the external portal. Faxes will not be accepted.

Affected codes: 29914, 29915, 29916
Portal: www.uhcprovider.com/paan
Faxes not accepted

Documentation Required

Document functional status and prior therapies

Provide documentation of the member's pain severity and functional disability interfering with activities of daily living using validated scales, include the physician's treatment plan and pertinent joint exam, and list prior therapies or treatments tried, failed, or contraindicated with dates and reasons for discontinuation.

Use standard scales such as WOMAC or HOOS

Coding

Referenced CPT / Procedure Codes (informational - may be covered depending on criteria)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

HCPCSHCPCS

S2118

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

Background & Evidence Summary

This policy summarizes that hip surgery, including arthroscopy for FAI, is medically necessary in certain circumstances and that InterQual CP procedures are used to determine specific medical necessity criteria for diagnostic and surgical hip procedures. It emphasizes that surgical treatment for FAI 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), and that detailed medical record documentation may be required to assess clinical criteria.

The policy rationale is informed by clinical evidence and InterQual guidance noting poorer outcomes and higher failure or conversion-to-THA rates when preexisting osteoarthritis or advanced cartilage damage are present, highlighting the need for careful patient selection. Operational and coding clarifications (for example, procedures considered integral to primary hip surgery and radiographic grading requirements for FAI arthroscopy CPT codes) are included to guide documentation, billing, and review.

Evidence	Key Finding
Migliorini et al., 2025 (systematic review, mean ~130 months follow-up)	32% of patients required conversion to total hip arthroplasty within ten years; highlights need for careful patient selection and consideration of factors like osteoarthritis and age.
FAIT RCT (Palmer et al., 2025)	At 38 months HOS ADL: arthroscopy mean 84.2 vs physiotherapy mean 74.2; between-group difference 8.9 (95% CI 7.0 to 10.8), favoring surgery for ADLs.
Lei et al., 2019 (meta-analysis of prognostic impact of OA)	Conversion to THA higher with preexisting OA: 37.3% in FAI with OA vs 9.7% in FAI without OA; overall failure rate significantly higher with OA.

Definitions (compact)

Disabling PainWOMAC pain domain > 40

Functional DisabilityWOMAC functional limitation domain > 40

FAI SyndromeAbnormal contact between femoral head and acetabulum from congenital formation or bone overgrowth (Pincer, Cam, Combined)

Revision History

05/01/2026code_description_updateLatest

Revised description for CPT codes 27299 and 29999 in the Femoroacetabular Impingement (FAI) Syndrome section (policy history notes update).

05/01/2026billing_policy_changeLatest

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