Surgery of the Hip (for Nebraska Only)
Defines medical necessity and coverage considerations for hip surgeries (arthroscopy, arthrotomy, hemiarthroplasty, total hip arthroplasty, and procedures for Femoroacetabular Impingement) for UnitedHealthcare members in Nebraska.
Revised description for CPT codes 27299 and 29999.
Added notation that iliopsoas tendon release, capsular repair, and capsular release surgery are integral to the primary hip procedure and not separately reimbursable; debridement during hip arthroscopy is integral to FAI surgery CPT codes 29914, 29915, and 29916 and not separately reimbursable.
Updated definition of 'Radiographic Findings of Osteoarthritis'.
Updated References section to reflect the most current information and archived previous policy version CS056NE.Z.
Coverage Criteria and Policy Scope
Medical necessity criteria (InterQual-referenced) and FAI exclusion
Covered when ALL of the following are met per referenced InterQual CP criteria and submitted documentation:
See InterQual CP references listed in policy; provider must supply supporting documentation for review.
Imaging grading (Tönnis/Outerbridge) and PROMs are specifically required for authorization of FAI arthroscopy codes (29914, 29915, 29916).
This exclusion applies to FAI arthroscopy codes and is a basis for denial; see policy coding notes regarding integral procedures and bundling.
Clinical evidence synthesis
Clinical evidence summaries regarding arthroscopic hip surgery for FAI and comparison to nonoperative care:
Study limitations include single-surgeon enrollment, bilateral randomization per hip, and majority male cohort.
The number of high-quality RCTs is limited; several meta-analyses included few RCTs and a mix of study designs.
Most evidence demonstrating improvements is limited to patients without advanced radiographic osteoarthritis.
Consider radiographic OA (Tönnis grading) when assessing candidacy for arthroscopy; advanced OA is an exclusion for FAI procedures per policy.
Surgical treatment for Femoroacetabular Impingement (FAI) Syndrome is considered unproven and not medically necessary when there is evidence of advanced osteoarthritis or severe cartilage damage. Specifically, arthroscopic or other surgical management of FAI is not medically necessary in the presence of Tönnis Grade 2 or 3 radiographic osteoarthritis and/or Outerbridge Grade III or IV cartilage injury.
Surgeries of the hip are procedural interventions and therefore are not regulated by the U.S. Food and Drug Administration; however, devices and instruments used during hip surgery may require FDA clearance or approval. FDA status alone does not determine coverage; refer to device-specific regulatory information as needed and to the policy language regarding coding, billing, and integral procedures for guidance on reimbursement.
For Femoroacetabular Impingement procedures (including CPTs 29914, 29915, 29916), the policy explicitly states that surgical treatment is not medically necessary when there is Tönnis Grade 2–3 radiographic osteoarthritis or Outerbridge Grade III–IV cartilage damage.
The policy updates the definition of Radiographic Findings of Osteoarthritis and emphasizes that the presence of radiographic OA affects coverage determinations for FAI surgery. Radiographic osteoarthritis (as graded by Tönnis) is associated with higher failure rates and an increased likelihood of conversion to total hip arthroplasty (for example, a 37.3% conversion rate reported in the FAI-with-OA group), which supports treating advanced OA as an exclusion for FAI surgical procedures.
CPT/HCPCS Codes and Related Metrics
| 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. |
| 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. |
| 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. |
| 27299 | Revised description for femoroacetabular impingement (per policy update). |
| 29999 | Revised description (per policy update). |
| 29914 | Arthroscopic hip surgery — debridement (considered integral to FAI surgery and not separately reimbursable when performed as part of primary procedure). |
| 29915 | Arthroscopic hip surgery — acetabuloplasty (integral to FAI surgery per policy; not separately reimbursable when part of primary procedure). |
| 29916 | Arthroscopic hip surgery — labral repair (integral to FAI surgery per policy; not separately reimbursable when part of primary procedure). |
Provider Responsibilities, Documentation, and Billing Guidance
InterQual criteria and prior authorization
Click here to view the InterQual® criteria. Prior authorization decisions are informed by InterQual medical necessity criteria; include InterQual reference or attach InterQual printout when submitting a prior authorization.
- Prior authorization: submit InterQual criteria reference or summary with request
- Required documentation listed below supports InterQual review
FAI with advanced OA/cartilage damage
Surgical treatment for Femoroacetabular Impingement (FAI) Syndrome is considered unproven and not medically necessary in the presence of advanced osteoarthritis (Tönnis Grade 2–3) and/or severe cartilage damage (Outerbridge Grade III–IV). Requests for surgery in patients meeting these radiographic/cartilage damage thresholds are likely to be denied.
- Tönnis Grade 2 or 3 = denial risk
- Outerbridge Grade III or IV = denial risk
Required medical record documentation
Provide complete medical record documentation to support clinical review. Incomplete records may delay review or result in denial.
- Imaging reports with complete diagnostic interpretation, impression, and interpreting provider specialty
- Radiographic grading (Tönnis or Outerbridge) for cartilage damage when FAI codes (29914, 29915, 29916) are requested
- Diagnostic images upon request (MRI, CT, X‑ray, bone scan) labeled with date and member identifiers; submit images via external portal when requested (www.uhcprovider.com/paan)
Clinical documentation supporting indication
Documentation must clearly distinguish FAI from osteoarthritis and demonstrate severity of pathology and symptoms for surgical indication.
- History and symptom chronology differentiating primary FAI versus degenerative OA
- Physical exam findings specific to FAI (e.g., positive impingement tests, range-of-motion deficits) and functional limitations
- Objective imaging findings (cam/pincer morphology, labral tear, cartilage status) with corresponding radiographic grade
- Patient-reported outcome measures (PROMs) such as WOMAC, HOOS, iHOT with baseline scores
- Detailed prior treatment history including type, duration, dates, and reason for failure or contraindication
Prognostic considerations
List poor prognostic factors that predict worse outcomes or higher failure rates after hip-preserving surgery; include these factors in the record when present.
- Advanced preoperative osteoarthritis
- Advanced articular cartilage disease
- Older patient age
- More severe preoperative pain
Conservative therapy considerations
Conservative therapy should be documented and typically attempted before surgical consideration for FAI. Provide dates, duration, and outcomes of nonoperative management.
- Documented course of conservative care (e.g., structured physiotherapy/rehabilitation) with duration and adherence
- Use of activity modification, NSAIDs, and targeted physical therapy with documented response
- If injections were used, document type, date(s), and clinical response
- Failure of conservative measures or contraindication to conservative care must be clearly stated and supported by records
Background and Rationale
Femoroacetabular Impingement (FAI) is caused by abnormal contact between the femoral head–neck junction and the acetabulum (cam, pincer, or combined morphologies) leading to labral tears and progressive cartilage damage. Patients typically present with hip or groin pain, decreased internal rotation and flexion, and activity-related symptoms. Arthroscopic management (femoroplasty, acetabuloplasty, labral repair, debridement) is aimed at correcting bony morphology and repairing soft-tissue injury, while arthroplasty addresses end-stage joint degeneration. Patient selection is critical: outcomes after arthroscopy are generally better in patients without radiographic osteoarthritis or severe cartilage loss, whereas presence of OA or advanced cartilage damage is associated with higher failure and conversion-to-arthroplasty rates, making arthroplasty the preferred option in those cases.
Definitions and Severity Grading
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.