CurrentUnitedHealthcarePolicy CSOS6OH.C

Surgery of the Hip (for Ohio Only)

This policy governs medical necessity and coverage considerations for surgical treatment of the hip, including procedures for Femoroacetabular Impingement (FAI) Syndrome, for UnitedHealthcare members in Ohio.

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Hip (for Ohio Only)

Policy CodePolicy CSOS6OH.C

Change TypeSupporting information added

Effective DateOct 1, 2025

Next Review Date

Key ActionSubmit medical records and apply InterQual procedural criteria for prior authorization review of surgical hip procedures.

SourceLink

POLICY UPDATE CHANGES

Medical Records Documentation Used for Reviews: Added language that benefit coverage is determined by the member specific benefit plan and applicable laws, and that medical records may be required to assess clinical criteria but do not guarantee coverage.

InterQualPrimary criteria

OhioApplicability

15+Procedure codes

WOMAC/HOOS/iHOT-33PROMs referenced

Coverage and Medical Necessity Criteria

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Covered with criteria (InterQual-based)

Covered when ALL of the following are met:

InterQual referenced coverage: Member meets the applicable InterQual procedural criteria for the requested hip surgery (see InterQual CP: Procedures).

Provider must document and apply the specific InterQual procedural criteria referenced by this policy

Procedures covered under InterQual: Requested procedure is one of the InterQual-listed procedures: hip arthroscopy (diagnostic or surgical), hip arthroscopy (pediatric), hemiarthroplasty, arthrotomy of the hip, removal and replacement/total joint replacement (TJR) of the hip, or total hip replacement/revision as applicable.

See policy for full list of CPT/HCPCS codes; listing of a code does not by itself imply coverage

Listing of a procedure or diagnosis code in this policy is for reference only and does not imply the service is covered. Benefit coverage is determined by the member-specific benefit plan and by applicable federal, state, or contractual requirements; inclusion of a code does not guarantee reimbursement or claim payment. FDA approval alone is not a basis for coverage and should not be interpreted as authorizing coverage for a service described by a listed code.

This policy does not enumerate every scenario that may be considered not medically necessary. Where a service or code is listed, that listing is not an affirmation of coverage; medical necessity must be established per the policy’s clinical criteria. FDA approval of a device or procedure is provided for informational purposes only and is not sufficient to establish coverage. Providers should expect that determinations of medical necessity will follow the criteria described in this policy and any referenced clinical tools (e.g., InterQual) and that member-specific benefits and applicable laws govern final coverage decisions.

Procedure and Assessment Codes / Key Clinical Thresholds

Arthroscopy and Related Hip ProceduresCPT

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).
27299	Unlisted procedure, pelvis or hip joint.
29914	Arthroscopy, hip, surgical; with femoroplasty (treatment of cam lesion).
29915	Arthroscopy, hip, surgical; with acetabuloplasty (treatment of pincer lesion).
29916	Arthroscopy, hip, surgical; with labral repair.
29999	Unlisted procedure, arthroscopy.

1–10 of 11

1/2

Arthroplasty / TJR CodesCPT

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 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 autograft or allograft.

HCPCSHCPCS

S2118

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

WOMAC pain or functional domain

WOMAC pain domain threshold> 40 (Western Ontario and McMaster Universities Arthritis Index)

Source study/referenceQuintana, 2009 as cited in policy definitions

PurposeDefines disabling pain for coverage considerations

Kellgren-Lawrence osteoarthritis grade

Kellgren-Lawrence grade requiredGrade 3 or 4 (definite narrowing/moderate to severe osteophyte formation and joint space narrowing)

Grade 3 descriptionDefinite narrowing of joint space, moderate osteophyte formation, some sclerosis, possible deformity of bony ends

Grade 4 descriptionLarge osteophytes, marked joint space narrowing, severe sclerosis, definite deformity of bony ends

Tonnis grade

Tonnis grades referencedGrades 1–3 described (Grade 1: slight changes; Grade 2: moderate changes; Grade 3: severe joint space loss and deformity)

Grade 1Increased sclerosis, slight joint space narrowing or slight slipping of joint margin, no or slight loss of head sphericity

Grade 2Small cysts in femoral head or acetabulum, moderate joint space narrowing, moderate loss of head sphericity

Grade 3Large cysts, severe joint space narrowing or obliteration, severe deformity of the head, possible avascular necrosis

Prior Authorization, Documentation, and Denial Risk

Prior Authorization

InterQual-based prior authorization

Surgical hip procedures are subject to medical necessity review using InterQual procedural criteria. Prior authorization is implied where applicable; check InterQual for specific operative criteria (e.g., arthroscopy, hemiarthroplasty, total joint replacement) before scheduling.

InterQual CP: Arthroscopy, Surgical, Hip
InterQual CP: Arthroscopy; Diagnostic, +/- Synovial Biopsy, Hip
InterQual CP: Arthroscopy, Surgical, Hip (Pediatric)
InterQual CP: Hemiarthroplasty, Hip
InterQual CP: Arthrotomy, Hip
InterQual CP: Removal and Replacement; Total Joint Replacement (TJR); Hip
InterQual CP: Total Joint Replacement (TJR), Hip

Note

Provider action / alert: verify applicable plan/contract requirements and InterQual criteria prior to requesting authorization; supply complete clinical documentation to support medical necessity.

Documentation Required

Medical records and benefit determination

Benefit coverage is determined by the member’s specific benefit plan document and applicable laws. Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage but providing records does not guarantee coverage.

Benefit coverage governed by member-specific plan and federal/state (OAC) or contractual requirements
Medical records may be requested to support criteria but do not ensure approval

Denial Risk

Denial triggers

Requests may be denied if the member does not meet InterQual criteria or if the submitted medical records do not support the required clinical criteria. If InterQual lacks applicable criteria, UnitedHealthcare may apply other approved Medical Policies, Coverage Determination Guidelines, or Utilization Review Guidelines as allowed by Ohio Medicaid requirements.

Denial possible when InterQual criteria are not met
Denial possible when documentation is incomplete or does not support the request
Alternate UnitedHealthcare policies/guidelines may be applied if InterQual criteria are unavailable

Definitions and Outcome Measures

FAI Syndrome

DefinitionFemoroacetabular Impingement (FAI) Syndrome: abnormal hip morphology (cam, pincer, or combined) causing abnormal bone contact and potential labral/cartilage damage with symptoms such as pain, limited internal rotation, and limp.

Cam morphologyLoss of sphericity of the femoral head with bony prominence (cam lesion) that grinds cartilage inside the acetabulum

Pincer morphologyExtraneous bone extends over acetabular rim (overcoverage) leading to labral crush; radiographic signs include lateral center edge angle > 40°, coxa profunda, or acetabular retroversion

Combined (mixed)Presence of both cam and pincer deformities

Disabling Pain / Functional Disability

Disabling Pain (WOMAC pain)> 40 on WOMAC pain domain (defines disabling pain)

Functional Disability (WOMAC function)> 40 on WOMAC functional limitation domain (defines functional disability)

Use in coverage decisionsWOMAC thresholds are used to define disabling pain/functional disability for clinical criteria

PROMs (HOOS, iHOT-33)

HOOSHip Disability and Osteoarthritis Outcome Score (HOOS): a 43‑question, self‑administered hip‑specific instrument assessing pain, symptoms, activities of daily living, sport/recreation, and hip‑related quality of life

iHOT-33International Hip Outcome Tool (iHOT‑33): 33‑item hip‑specific PROM for people with hip disorders (four subscales: symptoms/function, sport, job, social/emotional/lifestyle); scored 0–100

RoleReferenced as hip‑specific patient‑reported outcome measures to evaluate symptoms and function in FAI and hip osteoarthritis

OpenPayer

Surgery of the Hip (for Ohio Only)

Coverage and Medical Necessity Criteria

Procedure and Assessment Codes / Key Clinical Thresholds

Prior Authorization, Documentation, and Denial Risk

Clinical Background

Definitions and Outcome Measures