ModifiedUnitedHealthcarePolicy CSNCT0503.07

Surgery of the Hip (for North Carolina Only)

Clinical coverage policy for hip surgery (including arthroscopy and total hip arthroplasty) that applies only to North Carolina UnitedHealthcare members; describes medical necessity references, documentation requirements, and coding guidance.

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Hip (for North Carolina Only)

Policy CodePolicy CSNCT0503.07

Change TypeDefinition and coding clarifications (material)

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionWhen submitting prior authorization or claims, ensure billing aligns with guidance that certain procedures (iliopsoas tendon release, capsular repair/release, and debridement during hip arthroscopy) are integral to primary hip arthroscopy codes and are not separately reimbursable.

SourceLink

POLICY UPDATE CHANGES

Updated definition of 'Radiographic Findings of Osteoarthritis'.

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

Updated Clinical Evidence and References sections to reflect the most current information.

04/01/2026Policy revision date

applies toNorth Carolina only

Tönnis 2–3Advanced OA exclusion

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.

Outerbridge III–IV

Severe cartilage exclusion

29914–29916Primary hip arthroscopy codes

9.7%Conversion to THA (no OA)

Coverage Criteria

Coverage and Not Medically Necessary criteria

Covered when the referenced InterQual procedural criteria are met; specific FAI surgical treatment is excluded when advanced osteoarthritis or severe cartilage damage is present.

General coverage: Surgery of the hip and surgical treatment for Femoroacetabular Impingement (FAI) Syndrome is proven and medically necessary in certain circumstances; for specific clinical coverage criteria refer to InterQual CP: Arthroscopy (diagnostic/surgical), Arthrotomy, Hemiarthroplasty, Removal and Replacement TJR, and Total Joint Replacement (Hip).

See referenced InterQual criteria for detailed medical necessity elements.

Not medically necessary conditions for FAI surgery: Surgical treatment for FAI Syndrome is unproven and not medically necessary in the presence of advanced osteoarthritis and/or severe cartilage damage.Tönnis Grade 2 or 3; Outerbridge Grade III or IV

This exclusion applies to FAI-specific surgical treatment; refer to InterQual criteria for alternative covered hip procedures when appropriate.

Clinical evidence and applicability

Evidence-informed considerations and outcomes comparing arthroscopic surgery versus conservative therapy and factors affecting prognosis:

Evidence summary: Randomized trials, systematic reviews, and meta-analyses report that arthroscopic hip surgery can produce significant short- to medium-term improvements in patient-reported outcomes (e.g., iHOT, HOOS, EQ-5D) compared with conservative therapy for symptomatic FAI in selected patients without advanced osteoarthritis. Results vary by outcome measure and follow-up interval, and some analyses report no difference at early time points. Longer-term benefit, prevention of progression to total hip arthroplasty, and outcomes in the presence of radiographic osteoarthritis are less certain.

See cited RCTs, meta-analyses, and systematic reviews for study details and applicability.

Surgical treatment for Femoroacetabular Impingement (FAI) Syndrome is considered unproven and not medically necessary when significant degenerative joint disease is present. Specifically, procedures for FAI are not covered in the presence of Tönnis Grade 2 or 3 radiographic osteoarthritis and/or Outerbridge Grade III or IV focal cartilage damage.

Radiographic evidence of osteoarthritis is associated with poorer surgical prognosis after arthroscopic management of FAI. Meta-analytic data demonstrate that patients with radiographic OA have a significantly higher overall failure rate and a markedly increased rate of conversion to total hip arthroplasty compared with patients without OA.

When preoperative imaging shows Tönnis Grade 2 or 3 changes, surgical correction of FAI is considered unproven and not medically necessary. The presence of these advanced radiographic osteoarthritis grades identifies a population in which arthroscopic FAI procedures are unlikely to provide the expected benefit.

Advanced radiographic osteoarthritis correlates with higher rates of procedural failure and conversion to total hip arthroplasty: pooled analyses report a conversion rate of 37.3% in FAI patients with OA versus 9.7% in those without OA, supporting exclusion of arthroscopic FAI interventions in patients with established OA.

Coding and Applicable Procedure Codes

Applicable Procedure CodesCPT | HCPCS

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).
27132	Conversion of previous hip surgery to total hip arthroplasty, with or without autograft or allograft.
27134	Revision of total hip arthroplasty; both components.
27137	Revision of total hip arthroplasty; acetabular component only.

1–10 of 17

1/2

Primary hip arthroscopy CPT codes (integral procedures not separately reimbursable)CPTCovered

29914	Hip arthroscopy; with femoroplasty (eg, CAM lesion)
29915	Hip arthroscopy; with acetabuloplasty (eg, pincer lesion)
29916	Hip arthroscopy; combined femoroplasty and acetabuloplasty

inv-09: Radiographic criteria for severe osteoarthritis — Tönnis and Outerbridge grading guidance

Tönnis gradingTönnis Grade 2 or 3 indicates advanced radiographic osteoarthritis (Grade 2: small cysts, moderate joint-space narrowing and loss of head sphericity; Grade 3: large cysts, severe joint-space narrowing or obliteration and severe deformity)

Outerbridge cartilage gradingOuterbridge Grade III or IV denotes severe cartilage damage (Grade III: fissuring to subchondral bone >1.5 cm; Grade IV: exposed subchondral bone)

Radiographic features accepted for severe OANarrowing of joint space, osteophyte formation, subchondral sclerosis, subchondral cysts, deformity of bony end-plates, and thinning or loss of articular cartilage

Operational acceptance thresholdUnitedHealthcare will accept three or more moderate-to-severe radiographic findings as sufficient to support a diagnosis of severe osteoarthritis

Provider Actions and Prior Authorization

Prior Authorization

Prior Authorization and Applicable Codes

Prior authorization is required for surgical treatment of femoroacetabular impingement (FAI) when specified by the member's benefit plan and contract. Providers must verify benefit coverage and obtain any required prior authorization before scheduling procedures.

Check member-specific federal/state/contractual plan requirements before using this policy
When prior authorization is requested, include full medical record documentation (see Documentation callout)
Use InterQual criteria when applicable as a utilization management tool

Denial Risk

Integral Procedures — Separate Reimbursement Risk

Certain procedures are considered integral to the primary hip procedure and are not separately reimbursable. If billed separately, they may be denied as not separately payable.

Background

Femoroacetabular impingement (FAI) is caused by abnormal bony morphology of the proximal femur and/or acetabulum that produces pathologic contact during hip motion. The common patterns are cam lesions (aspheric femoral head-neck junction), pincer lesions (acetabular overcoverage), or a combined deformity. This abnormal contact predisposes to labral tears and progressive chondral injury, which manifests clinically as groin pain, limited internal rotation, and may lead to osteoarthritis if untreated.

Definitions and Outcome Measures

inv-19: Disabling Pain (WOMAC pain domain > 40)

DefinitionDisabling Pain is defined as Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain domain > 40 (Quintana, 2009).

InstrumentWOMAC pain domain (part of the WOMAC questionnaire), a disease-specific self-administered scale for hip or knee OA

Use in policyThreshold >40 is used to identify pain severity supporting clinical assessment for FAI-related interventions

inv-20: Femoroacetabular Impingement (FAI) Syndrome definition

DefinitionFemoroacetabular Impingement (FAI) Syndrome occurs from congenital hip formation anomalies or bone overgrowth around the femoral head and/or acetabulum causing abnormal contact, labral tears, and articular cartilage breakdown (osteoarthritis)

FAI types

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Hip (for North Carolina Only)

Policy CodePolicy CSNCT0503.07

Change TypeDefinition and coding clarifications (material)

Effective DateApr 1, 2026

Next Review DateN/A

SourceLink

On This Page

Iliopsoas tendon release surgery, capsular repair, and capsular release are considered integral to the primary hip procedure and not separately reimbursable

Debridement during hip arthroscopy is considered integral to the FAI surgery CPT codes 29914, 29915, and 29916 and would not be separately reimbursable

When requesting prior authorization, indicate if any of these integral procedures will be performed as part of the primary procedure

Documentation Required

Required Medical Record Documentation

Complete medical record documentation may be required for benefit determination and prior authorization reviews. Submission of records does not guarantee coverage.

Complete diagnostic interpretation of imaging with relevant clinical information and an impression
Documentation of presence/absence, size, location, and Outerbridge grade of focal full-thickness articular cartilage defects
Joint space, alignment, and any radiographic osteoarthritis grading (e.g., Tönnis grade)
Reports of recent diagnostic tests (MRI, CT, X-ray), with images labeled with date and member identifiers when requested; submit images via the external portal at www.uhcprovider.com/paan (faxes not accepted)
Condition requiring procedure, symptoms, severity of pain, functional disabilities, and cause of defect
Pertinent physical examination findings, comorbidities, prior therapies/treatments tried (with dates, duration, and reason for discontinuation), and date of failed previous surgery if applicable
Physician's treatment plan including pre-op discussion and any additional intraoperative interventions or products; for revision surgery include details of complication and complete staged surgical plan
For inpatient requests, documentation supporting at least one: bilateral surgery, significant comorbidities, or inability to support outpatient post-operative care

Note

Conservative Therapy Considerations

Conservative therapy should be attempted and documented prior to considering arthroscopic surgery when clinically appropriate. Documentation must include the type, duration, response, and reason for discontinuation of conservative measures.

Conservative management may include physical therapy, activity modification, analgesics, injections, and other non-operative interventions
Record duration and specifics of physical therapy and other non-operative treatments and objective measures of response
If conservative therapy was not appropriate or contraindicated, document the clinical rationale

Note

Conservative Therapy — RCTs and Meta-analyses

Evidence from randomized controlled trials and meta-analyses shows mixed findings comparing arthroscopy versus conservative care. When prior authorization is requested, include documentation of prior conservative care and relevant trial evidence or rationale for proceeding to surgery, especially if alternative management options were available.

Include documentation of trials of conservative therapy (dates, modalities, outcomes) when claiming failure of non-operative care
Be aware that some meta-analyses report superior short- to mid-term patient-reported outcomes with arthroscopy versus conservative therapy in select patients, but results vary by outcome and follow-up interval
Carefully document patient selection factors (age, presence/degree of OA, cartilage status, symptom severity) that align with evidence supporting surgical benefit

Note

Coverage Decision Guidance

Coverage decisions must follow the member's federal, state, and contractual plan requirements. This policy is informational and may be superseded by specific plan provisions or applicable law.

Before approving or denying, check the member's benefit plan language and any statutory or regulatory mandates that apply
In the event of conflict, federal, state, or contractual requirements govern over this policy
Use this policy in conjunction with InterQual or other third-party tools as applicable; documentation and clinical criteria must support medical necessity

Pincer (acetabular overcoverage, lateral center edge angle >40°; coxa profunda; acetabular retroversion), Cam (loss of femoral head sphericity, alpha angle >50°), Combined (both features present)

Clinical consequencesResults in pain, stiffness, limited internal rotation, limping, and progressive joint damage

inv-21: Functional Disability (WOMAC functional limitation > 40)

DefinitionFunctional Disability is defined as Western Ontario and McMaster Universities Arthritis Index (WOMAC) functional limitation domain > 40 (Quintana, 2009).

InstrumentWOMAC functional limitation domain, part of the 24-item WOMAC assessing pain, stiffness, and physical function

Clinical useThreshold >40 used to quantify significant functional impairment in policy assessments

inv-22: HOOS — hip-specific PROM description

InstrumentHip Dysfunction and Osteoarthritis Outcome Score (HOOS) is a self-administered, hip-specific PROM consisting of 43 items across five subscales: pain, symptoms, function in daily living, function in sport/recreation, and hip-related quality of life

PurposeUsed to evaluate symptoms and functional limitations and commonly applied to assess interventions in hip dysfunction and osteoarthritis

Scoring domainsFive subscales capture pain, symptoms, activities of daily living, sports/recreation, and quality of life

inv-23: iHOT-33 — patient-reported outcome tool description

InstrumentInternational Hip Outcome Tool (iHOT-33) is a patient-reported outcome measure for hip disorders composed of 33 items across four subscales (Symptoms/Functional limitations 16 items; Sport 6 items; Job 4 items; Social/Emotional/Lifestyle 7 items)

ScoringEach item is answered 0–100; the final score is the sum of item scores divided by 33

ApplicationRecommended as a reference PROM for assessing outcomes in patients with FAI and other hip disorders

inv-24: Radiographic Findings of Osteoarthritis (updated definition)

Updated definition (policy)Radiographic Findings of Osteoarthritis include narrowing of joint space, osteophyte formation, subchondral sclerosis, subchondral cysts, deformity of bony end-plates, and thinning or complete loss of articular cartilage (ACR, 2025)

Operational thresholdUnitedHealthcare will accept three or more moderate-to-severe radiographic findings to support a diagnosis of severe osteoarthritis

Clinical relevancePresence of radiographic OA (higher Tönnis grade or multiple radiographic findings) is associated with worse outcomes and higher conversion to total hip arthroplasty