RetiredUnitedHealthcarePolicy CS056LA.S

Hip surgery and surgical treatment for Femoroacetabular Impingement (FAI) Syndrome — Coverage Criteria

Defines medical necessity and coverage guidance for hip surgery including arthroscopy, arthrotomy, hemiarthroplasty, and total hip arthroplasty for members in Louisiana; includes documentation requirements, definitions, applicable codes, and evidence summaries.

Policy Summary

PayerUnitedHealthcare

PolicyHip surgery and surgical treatment for Femoroacetabular Impingement (FAI) Syndrome — Coverage Criteria

Policy CodePolicy CS056LA.S

Change TypeDocumentation and operational editspolicy retired for LA membership

Effective DateJan 1, 2026

Next Review Date

Key ActionSubmit required medical records and labeled diagnostic images (when requested) via the external portal to support prior authorization and clinical review.

SourceLink

POLICY UPDATE CHANGES

Medical Records Documentation Used for Reviews: added language specifying required imaging interpretation details and, for FAI (CPT 29914–29916), radiographic reports using Tönnis or Outerbridge grading.

Added list of medical notes that may be required upon request, including condition requiring procedure, severity of pain with functional disability using standard scales, prior therapies tried/failed, and pertinent physical exam.

Policy was retired for Louisiana membership as of April 1, 2026.

One statepolicy applies to

Tönnis ≥2FAI w/ advanced OA

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria and Evidence Considerations

Medical necessity — Covered when meeting InterQual criteria and not meeting exclusion criteria

Covered when meeting InterQual criteria and not meeting exclusion criteria.

Primary coverage logic: Surgery of the hip and surgical treatment for Femoroacetabular Impingement (FAI) Syndrome is proven and medically necessary in certain circumstances per InterQual CP procedures (arthroscopy diagnostic, arthroscopy surgical, arthrotomy, hemiarthroplasty, total joint replacement).

Refer to InterQual CP for the specific clinical coverage criteria and the list of applicable InterQual procedures referenced in policy (see InterQual CP: Procedures).

Not medically necessary — Not covered / not medically necessary when any of the following apply

Not covered / not medically necessary when any of the following apply:

Exclusion logic: Surgical treatment for FAI is unproven and not medically necessary in the presence of advanced osteoarthritis and/or severe cartilage damage.Tönnis Grade >=2; Outerbridge Grade III-IV; Kellgren-Lawrence grade 3-4

Radiographic classifications (Tönnis, Outerbridge, Kellgren-Lawrence) define thresholds for advanced disease; presence at or above these grades contraindicates surgical treatment for FAI as stated in policy.

Evidence-based coverage considerations — Evidence summary and coverage-relevant clinical considerations

Evidence summary and coverage-relevant clinical considerations:

Outcomes evidence: Randomized trials and meta-analyses show arthroscopic hip surgery can provide superior short- to mid-term patient-reported outcomes (iHOT-33, HOOS, EQ-5D) compared with physiotherapy in some analyses, but the number of high-quality RCTs is small and follow-up is generally short (most ≤24 months).Follow-up typically 12–24 months

See Gatz et al. (2020) meta-analysis and related trials; mean follow-up in pooled RCTs ~14.7 months (chunk 19).

Impact of osteoarthritis on outcomes: Presence of radiographic osteoarthritis is associated with higher failure rates and greater conversion to total hip arthroplasty after surgical management of FAI (reported conversion ~37.3% with OA vs 9.7% without OA).

Lei et al. (2019) meta-analysis and Gohal et al. (2019) systematic review report higher failure and conversion rates when OA is present (chunk 21).

Evidence limitations and need for long-term data:

Surgical treatment for Femoroacetabular Impingement (FAI) is explicitly considered not medically necessary when there is evidence of advanced hip osteoarthritis or severe cartilage damage. The policy states that FAI surgery is unproven and not medically necessary in the presence of Tönnis Grade 2 or 3 radiographic osteoarthritis and/or Outerbridge Grade III or IV full-thickness cartilage damage.

Systematic reviews and meta-analyses indicate that the presence of radiographic hip osteoarthritis is associated with poorer outcomes after arthroscopic treatment of FAI, including higher overall failure rates and substantially increased conversion to total hip arthroplasty. For example, pooled data reported a conversion rate to total hip arthroplasty of 37.3% in patients with FAI plus OA versus 9.7% for FAI without OA, and authors note that many HRQL outcome studies excluded patients with advanced OA when reporting favorable results at 12–24 months.

The policy reiterates that surgical management of FAI is unproven and not medically necessary if imaging demonstrates advanced osteoarthritis (Tönnis Grade 2 or 3) or severe cartilage damage (Outerbridge Grade III or IV), and lists these findings as exclusion criteria for coverage of hip surgical procedures for FAI.

Clinical studies show that arthroscopic treatment of FAI in patients with radiographic evidence of osteoarthritis has higher failure and conversion rates compared with patients without OA. Meta-analytic data demonstrate increased conversion to total hip arthroplasty and worse outcomes when OA is present, although some prospective series report improvements in patients with mild to moderate OA (Tönnis 1–2) at two-year follow-up; these findings support the policy stance that outcomes are generally worse as radiographic OA severity increases.

Applicable Procedure and Billing Codes

Applicable procedure codes (part 1)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).

Applicable procedure codes (part 2)CPT

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.
27299	Unlisted procedure, pelvis or hip joint.
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.

HCPCSHCPCS

S2118

Metal-on-metal total hip resurfacing, including acetabular and femoral components (HCPCS).

FAI Arthroscopy CPT Codes referenced for documentation requirementsCPT

29914	Arthroscopic hip surgery — CPT code referenced for FAI
29915	Arthroscopic hip surgery — CPT code referenced for FAI
29916	Arthroscopic hip surgery — CPT code referenced for FAI

WOMAC thresholds — Disabling pain / Functional disability (policy definitions)

WOMAC pain domain thresholdDisabling pain defined as WOMAC pain domain > 40 (Quintana, 2009)

WOMAC function domain thresholdFunctional disability defined as WOMAC functional limitation domain > 40 (Quintana, 2009)

Source contextWOMAC is a 24-item self‑administered questionnaire with pain, stiffness, and physical function domains used to evaluate hip osteoarthritis

Radiographic and cartilage severity thresholds

Tönnis radiographic OA thresholdTönnis Grade 2–3 indicates moderate to severe radiographic osteoarthritis (Grade 2: moderate joint space narrowing; Grade 3: severe narrowing/ deformity)

Prior Authorization, Documentation, and Actionable Provider Requirements

Prior Authorization

Prior Authorization Required

Prior authorization (pre-service review) is required for surgical treatment of femoroacetabular impingement (FAI) and related hip arthroscopy procedures. Authorization/clinical review requires submission of complete medical records and diagnostic imaging as described below. Failure to submit requested records or labeled diagnostic images when requested may result in denial or delay.

Prior authorization must be obtained before scheduling outpatient or inpatient hip arthroscopy for FAI (including CPT 29914, 29915, 29916).
When requested, diagnostic image(s) must be submitted via the external portal at www.uhcprovider.com/paan; faxes will not be accepted.

Documentation Required

Imaging and Documentation Requirements for Prior Authorization

Medical documentation must include a complete diagnostic interpretation of imaging findings. At minimum provide relevant clinical information, a detailed report of imaging findings, the interpreting provider specialty(ies), and a clear impression. For FAI specifically, include radiographic reports documenting presence and severity of cartilage damage using Tönnis or Outerbridge grading where applicable.

Clinical Background and Scope

Femoroacetabular Impingement (FAI) results from abnormal bone morphology and hip joint alignment that produces pathological contact between the femoral head/neck and the acetabulum. The three classic morphologies are cam lesions (loss of femoral head sphericity), pincer lesions (acetabular overcoverage), and combined deformities. These structural abnormalities can produce labral tears, progressive cartilage damage, hip pain, and limited range of motion. Worse preoperative osteoarthritis, advanced cartilage disease, older age, and greater baseline pain or functional impairment are associated with poorer surgical outcomes.

Definitions and Classifications

Femoroacetabular Impingement (FAI) Syndrome — definition and examples

Definition (concise)Femoroacetabular Impingement (FAI) Syndrome: abnormal contact between the femoral head and acetabulum due to cam, pincer, or combined morphology causing labral tears and articular cartilage breakdown

Types of FAIPincer (acetabular overcoverage), Cam (loss of femoral head sphericity), Combined (both features)

Radiographic criteria examplesExamples include lateral center edge angle > 40° for pincer and alpha angle > 50° for cam morphology

Outerbridge, Tönnis, Kellgren-Lawrence classifications

Outerbridge grading (cartilage)Grade 0: normal; I: softening/swelling; II: partial‑thickness defect ≤1.5 cm; III: fissuring to subchondral bone >1.5 cm; IV: exposed subchondral bone

Tönnis classification (radiographic OA)

Policy Summary

PayerUnitedHealthcare

PolicyHip surgery and surgical treatment for Femoroacetabular Impingement (FAI) Syndrome — Coverage Criteria

Policy CodePolicy CS056LA.S

Change TypeDocumentation and operational editspolicy retired for LA membership

Effective DateJan 1, 2026

Next Review Date

Key ActionSubmit required medical records and labeled diagnostic images (when requested) via the external portal to support prior authorization and clinical review.

SourceLink

On This Page

Include reports of recent diagnostic tests (e.g., MRI, CT, X-ray, bone scan) and any microbiological or synovial exam results, ESR, CRP when relevant.
When specific diagnostic images are requested, submit the actual image files labeled with the date taken and the applicable case number obtained at time of notification or the member's name and ID number on the image(s).
Upon request, diagnostic image(s) must be submitted via the external portal at www.uhcprovider.com/paan; faxes will not be accepted.

Documentation Required

Required Clinical Documentation

Medical records should fully document the clinical condition and prior management to allow assessment of medical necessity. Provide history of the condition, symptoms, severity of pain, functional limitations, and a physician's treatment plan. Document prior conservative therapies tried, failed, or contraindicated (with dates, duration, and reason for discontinuation). For revision procedures, include details of the complication and the complete staged surgical plan.

Document condition requiring the procedure, cause of defect (acute or repetitive trauma), and pertinent physical examination of the relevant joint.
Include severity of functional disability using a standard scale when available (e.g., WOMAC or HOOS).
Provide comorbid medical conditions and relevant treatment, and date of failed previous surgery to the same joint if applicable.

Note

Non-surgical Therapy Context

Non-surgical therapy (physiotherapy and other conservative management) is commonly used and should be documented as part of the clinical history. Although not required as a formal step-therapy program in this policy, prior non-operative management including supervised physiotherapy, activity modification, medication trials, and other conservative measures should be detailed (dates, duration, and response) to support the medical necessity assessment for surgery.

List specific non-surgical therapies attempted, dates and duration, and reason for discontinuation or failure.
Describe functional impact and ongoing symptoms despite conservative care to justify surgical consideration.

Documentation Required

Inpatient Stay Documentation

If the requested location is inpatient, provide documentation that supports one or more of the following: bilateral surgery, significant comorbidities (with current treatment), or lack of appropriate resources for outpatient post-operative care. Lack of these supporting notes may result in denial of inpatient setting.

For inpatient requests include the list of comorbidities and current treatments that necessitate inpatient care.
Document barriers to safe outpatient postoperative care when claiming inpatient necessity.

Denial Risk

Denial Trigger: Advanced Osteoarthritis or Severe Cartilage Damage

Surgical treatment for FAI is not medically necessary in the presence of advanced osteoarthritis (Tönnis Grade 2 or 3) and/or severe cartilage damage (Outerbridge Grade III or IV). When such findings are present on imaging reports, include them explicitly — absence of this documentation may trigger denial.

If imaging demonstrates Tönnis Grade 2–3 osteoarthritis or Outerbridge Grade III–IV cartilage damage, note that arthroscopic surgery for FAI is considered unproven and not medically necessary.
Provide clear imaging-based gradings in the report to allow accurate review.

Denial Risk

Documentation-linked Denial Risk

Failure to provide required medical records and diagnostic imaging (including labeled images upon request), or failure to document prior conservative management, functional limitations, and imaging grades (Tönnis/Outerbridge) may result in denial or delay of authorization.

Ensure requested records and images are submitted through the portal www.uhcprovider.com/paan; do not fax images when requested.
Include interpreter specialty(ies) and a clear impression in imaging reports to reduce risk of clarification requests or denial.

Patient‑reported outcome measures referenced

WOMACWestern Ontario and McMaster Universities Arthritis Index — 24 items covering pain, stiffness, and physical function; thresholds >40 define disabling pain/functional disability

HOOSHip Dysfunction and Osteoarthritis Outcome Score — 43 items across five subscales for hip‑specific symptoms, function, and quality of life

iHOT-33International Hip Outcome Tool (33 items) for patients with hip disorders, covering symptoms, sport, job concerns, and social/lifestyle domains

Radiographic osteoarthritis impact on FAI outcomes

Impact on surgical outcomesPresence of radiographic osteoarthritis in FAI patients is associated with higher overall failure rates and increased conversion to total hip arthroplasty (conversion 37.3% with OA vs 9.7% without OA)

Evidence sourceLei et al. (meta-analysis) and Gohal et al. systematic review report worse outcomes and higher THA conversion in FAI with radiographic OA

Clinical implicationAdvanced radiographic OA or severe cartilage damage may contraindicate arthroscopic FAI treatment due to higher failure/ conversion rates