UnitedHealthcare Hip Surgery Coverage Update

Coverage Criteria for Hip Surgery (Including FAI)

Coverage when InterQual criteria met

Surgical hip procedures are considered medically necessary when the member meets the clinical decision logic defined by the referenced InterQual procedural protocols.

InterQual-based medical necessity: Refer to InterQual CP procedural protocols for determination of medical necessity: Arthroscopy, Diagnostic +/- Synovial Biopsy, Hip; Arthroscopy, Surgical, Hip; Arthroscopy, Surgical, Hip (Pediatric); Arthrotomy, Hip; Hemiarthroplasty, Hip; Removal and Replacement, Total Joint Replacement (TJR), Hip; Total Joint Replacement (TJR), Hip.

Medical necessity determinations for the listed hip surgical procedures follow the specific clinical criteria and decision logic contained in the InterQual CP procedural protocols. Listing of CPT codes in this policy is for reference; benefit coverage is governed by the member-specific plan document.

Evidence considerations for coverage

Coverage decisions should consider the following evidence-based points:

Evidence and patient selection: Hip arthroscopy is associated with significant improvements in generic and hip-specific health-related quality-of-life outcomes at 12–24 months in patients without advanced hip osteoarthritis (Gohal et al.).

Supported by systematic reviews and prospective studies

Comparative effectiveness: Randomized and comparative studies show mixed results: some outcome measures (e.g., iHOT-33) favored arthroscopy at 12 months whereas other measures (HOOS, mHHS, NAHS, EQ-VAS) often show no significant difference versus nonoperative care (pooled analyses of 5 studies, 838 patients).

Effect varies by outcome measure and follow-up duration

Impact of osteoarthritis: Presence and severity of radiographic osteoarthritis are associated with higher overall failure rates and substantially higher rates of conversion to total hip arthroplasty after arthroscopic management of FAI (Lei et al.: conversion 37.3% with OA vs 9.7% without OA).

Consider OA severity (radiographic grading) when selecting patients for arthroscopy

Limitations and need for long-term data: Long-term outcomes beyond 1–2 years are inadequate to determine whether arthroscopy prevents progression to hip arthroplasty; heterogeneity of impingement morphologies, limited follow-up, and incongruence between clinical scores and patient-reported subjective change limit definitive conclusions.

Evidence gap: long-term efficacy and influence of perioperative factors (e.g., physiotherapy)

Listing of a code in this policy does not imply the service described by the code is a covered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws. Inclusion of a code does not guarantee reimbursement or claim payment; other policies and plan terms may apply.

Patients with radiographic evidence of advanced osteoarthritis have demonstrably worse outcomes after arthroscopic management of femoroacetabular impingement. Meta-analysis and pooled data show significantly higher overall failure rates and a greater rate of conversion to total hip arthroplasty in FAI patients with radiographic OA (for example, conversion rates of 37.3% with OA vs 9.7% without OA). These findings indicate higher risk of surgical failure and progression to arthroplasty in the presence of OA.

Available randomized and comparative studies typically report short-term (up to 12–24 months) improvements in selected patient-reported outcomes after hip arthroscopy for FAI in patients without advanced OA, but long-term evidence is limited. The relative benefit of arthroscopy versus nonoperative care varies by outcome measure and follow-up duration, further supporting careful selection of patients without advanced radiographic OA when considering arthroscopy.

Several preoperative factors are associated with poorer postoperative outcomes after hip surgery, including advanced preoperative osteoarthritis, advanced articular cartilage disease, and older age. More severe preoperative pain is also linked to worse subjective functional scores and higher rates of surgical failure. These prognostic factors should be considered when assessing expected benefit and medical necessity.

In patients with coexisting radiographic OA, data demonstrate higher failure and conversion rates and generally worse outcomes, indicating that cartilage status and OA severity are important determinants of prognosis.

Current evidence does not conclusively support performing arthroscopic correction with the expectation of preventing long-term joint degeneration or avoidance of future hip arthroplasty. Short- to mid-term trials are limited in duration and heterogeneous in measures, and long-term studies addressing whether arthroscopy alters the natural history of joint degeneration are insufficient. Therefore, arthroscopy should not be performed solely with the primary expectation of preventing progression to total hip arthroplasty.

Relevant Procedure and Diagnostic Codes

Arthroscopy, Diagnostic / Surgical, HipCPT

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.

Arthrotomy / Arthroplasty / Hemiarthroplasty / TJRCPT

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).
27132	Conversion of previous hip surgery to total hip arthroplasty.
27134	Revision of total hip arthroplasty; both components.
27137	Revision of total hip arthroplasty; acetabular component only.
27138	Revision of total hip arthroplasty; femoral component only.

FAI-specific / Unlisted / Resurfacingmixed

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.
27299	Unlisted procedure, pelvis or hip joint.
S2118	Metal-on-metal total hip resurfacing, including acetabular and femoral components.

WOMAC pain / functional domain — threshold

WOMAC pain domain thresholdWOMAC pain domain > 40

WOMAC functional domain thresholdWOMAC functional limitation domain > 40

Source/validationQuintana, 2009 as cited in policy definitions

Radiographic thresholds for FAI / OA

Alpha angle (cam)Alpha angle > 50°

Lateral center edge angle (pincer)Lateral center edge angle > 40° (or radiographic signs such as coxa profunda or acetabular retroversion)

Provider Actions, Authorization, and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required and services must meet medical necessity criteria. Requests will be reviewed using InterQual procedural protocols referenced in this policy; obtain prior authorization before scheduling elective procedures to avoid claim denials or delays.

InterQual protocols used for clinical review (see policy coverage rationale)
Failure to obtain prior authorization may result in denial or retrospective review

Note

Benefit Verification and Plan Applicability

Verify member-specific benefits and plan applicability prior to providing services. The member's benefit plan document and any applicable federal or state mandates control coverage determinations; if there is a conflict, the member-specific benefit plan governs.

Check eligibility, benefits, and any plan exclusions or limitations
Confirm whether Medicare Advantage rules, NCDs/LCDs, or state mandates apply

Background on Femoroacetabular Impingement and Hip Surgery

Femoroacetabular impingement (FAI) syndrome is caused by abnormal bony morphology of the proximal femur and/or acetabulum — classically cam (loss of femoral head sphericity, often with alpha angle > 50°), pincer (acetabular overcoverage, e.g., lateral center edge angle > 40°, coxa profunda, or retroversion), or a combined pattern — that produces abnormal contact between the femoral head–neck junction and the acetabular rim. This abnormal contact can lead to labral tears, progressive chondral damage, pain, stiffness, and restricted internal rotation.

Clinically, patients with FAI commonly present with activity-related groin pain, mechanical symptoms, and limited hip range of motion; labral pathology and cartilage injury are frequent concomitant findings. Surgical procedures, including hip arthroscopy for labral repair, femoroplasty, or acetabuloplasty, are established options for selected patients to address the anatomic abnormality and associated soft tissue injury, with patient selection influenced by symptom severity, functional impairment, and absence of advanced radiographic osteoarthritis.

Key Definitions and Classifications

Disabling Pain (WOMAC)

DefinitionDisabling pain defined as Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain domain > 40

Measurement instrumentWOMAC is a 24-item, multi-dimensional self-administered questionnaire assessing pain, stiffness, and physical function

ReferenceQuintana, 2009 as cited in policy definitions

Femoroacetabular Impingement (FAI) Syndrome

Core definitionFemoroacetabular Impingement (FAI) Syndrome: Abnormal bone morphology (pincer, cam, or combined) causing abnormal contact between femoral head and acetabulum, leading to labral tears, cartilage damage, pain, stiffness, and limited internal rotation

Pincer morphology

OpenPayer

Surgery of the Hip (including arthroscopy) for Femoroacetabular Impingement (FAI)

Coverage Criteria for Hip Surgery (Including FAI)

Relevant Procedure and Diagnostic Codes

Provider Actions, Authorization, and Documentation Requirements

Background on Femoroacetabular Impingement and Hip Surgery

Key Definitions and Classifications