ModifiedUnitedHealthcarePolicy CS056NM.F

Surgery of the Hip (for New Mexico Only)

Medical policy governing surgical treatment of hip conditions, including arthroscopy for Femoroacetabular Impingement (FAI) and total hip replacement, applicable to UnitedHealthcare members in New Mexico.

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Hip (for New Mexico Only)

Policy CodePolicy CS056NM.F

Change TypeCPT descriptor revisionscoding/reimbursement clarifications

Effective DateMay 1, 2026

Next Review Date

Key ActionSubmit prior authorization with medical records and imaging (including Tönnis/Outerbridge grading) for listed hip procedure codes when requesting coverage.

SourceLink

POLICY UPDATE CHANGES

Revised description for CPT codes 27299 and 29999.

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 CPT codes 29914, 29915, and 29916 and therefore not separately reimbursable.

Updated definition of 'Radiographic Findings of Osteoarthritis'.

Updated References section to reflect the most current information and archived the previous policy version CS056NM.E.

Tönnis 2–3Advanced OA threshold

Outerbridge III–IVSevere cartilage

29914–29916Primary FAI codes

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Coverage and Medical Necessity Criteria

Medical necessity and exclusion criteria (FAI and general hip surgery)

Covered when clinical coverage criteria are met per referenced InterQual procedures; however FAI surgery is excluded in specific situations.

InterQual criteria requirement: Surgery of the hip and surgical treatment for FAI Syndrome are considered proven and medically necessary in certain circumstances per InterQual CP procedures (see policy).

Refer to InterQual for detailed medical necessity criteria.

Exclusion for FAI surgery: Surgical treatment for Femoroacetabular Impingement (FAI) Syndrome is unproven and not medically necessary if advanced osteoarthritis (Tönnis Grade 2 or 3) and/or severe cartilage damage (Outerbridge Grade III or IV) are present.Tönnis Grade >=2 OR Outerbridge Grade >=III

Presence of these findings is a denial condition for FAI surgery.

Clinical Evidence Overview

Clinical evidence summary informing coverage decisions:

Evidence Summaries: Randomized trials and multiple systematic reviews/meta-analyses report that hip arthroscopy can improve hip-specific patient-reported outcomes and quality of life versus conservative care in selected populations; however results vary by outcome measure and follow-up time, and limitations include small sample sizes, short- to mid-term follow-up, single-surgeon trials, heterogeneous nonoperative protocols, and uncertain long-term effects and impact on osteoarthritis progression.

See cited trials and meta-analyses for details (e.g., Bonin et al. RCT; Mok 2021; Zhu 2022; Kim 2021; Gatz 2020; Lei 2019; Sansone 2015).

Surgical treatment for Femoroacetabular Impingement (FAI) Syndrome is considered unproven and not medically necessary when there is evidence of advanced osteoarthritis (Tönnis Grade 2 or 3) and/or severe cartilage damage (Outerbridge Grade III or IV). This exclusion applies to arthroscopic FAI procedures and other surgical interventions aimed at addressing impingement morphology when the specified radiographic or intraoperative cartilage thresholds are met.

Radiographic osteoarthritis adversely affects outcomes after surgical management of FAI. Pooled data show significantly higher overall failure rates and a notably greater rate of conversion to total hip arthroplasty when osteoarthritis is present — conversion to THA 37.3% with radiographic OA versus 9.7% without OA. Presence of radiographic OA should therefore be considered when evaluating expected benefit and coverage for FAI surgery.

Per the policy, FAI surgery is explicitly considered not medically necessary for members with Tönnis Grade 2 or 3 radiographic osteoarthritis or with Outerbridge Grade III or IV cartilage damage. When these grading thresholds are documented on imaging reports or intraoperative assessment, surgical treatment for FAI will not meet medical necessity criteria.

The policy notes limitations in the evidence base for FAI surgery: many trials have modest sample sizes (including single-surgeon RCTs), follow-up is generally short to midterm, and nonoperative comparator protocols are heterogeneous. These factors limit certainty about long-term benefits, effects on osteoarthritis progression, and generalizability of results, underscoring the need for larger, longer-term, multicenter studies with consistent outcome reporting.

Applicable Codes and Coding Guidance

Arthroscopy, Diagnostic and 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.

Arthrotomy, Hip; Arthroplasty; FAI arthroscopy codesCPT

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).

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HCPCSHCPCS

S2118

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

Applicable CPT codes with descriptor updates and integral procedure notesCPT

27299	Revised description for CPT code 27299 (unlisted procedure, pelvis or hip joint) as noted in policy history.
29999	Revised description for CPT code 29999 (unlisted procedure, arthroscopy) as noted in policy history.
29914	Arthroscopy, hip, surgical; with femoroplasty (treatment of cam lesion) — debridement during hip arthroscopy is considered integral to this FAI surgery code and is not separately reimbursable.
29915	Arthroscopy, hip, surgical; with acetabuloplasty (treatment of pincer lesion) — debridement during hip arthroscopy is considered integral to this FAI surgery code and is not separately reimbursable.
29916	Arthroscopy, hip, surgical; with labral repair — debridement during hip arthroscopy is considered integral to this FAI surgery code and is not separately reimbursable.

Radiographic / cartilage grading thresholds (Tönnis, Outerbridge)

Tönnis classificationGrade 2: small cysts, moderate joint-space narrowing, moderate loss of head sphericity; Grade 3: large cysts, severe joint-space narrowing or obliteration, severe deformity (Tönnis).

Outerbridge cartilage gradesGrade III: fissuring to subchondral bone >1.5 cm; Grade IV: exposed subchondral bone (Outerbridge).

Radiographic criteria for OA (components)Narrowing of joint space; osteophyte formation; subchondral sclerosis; subchondral cysts; deformity of bony end-plates; thinning or loss of articular cartilage.

UnitedHealthcare operational thresholdThree or more moderate-to-severe radiographic findings accepted as sufficient to support a diagnosis of severe osteoarthritis.

Conversion to Total Hip Arthroplasty — higher conversion rate with radiographic OA

Provider Responsibilities, Authorization, and Billing Notes

Prior Authorization

Prior Authorization May Be Required

Prior authorization may be required for listed hip procedure codes. Verify plan-specific requirements and submit authorization prior to scheduling when applicable.

Affected codes: include CPT codes for hip arthroscopy and related procedures (e.g., 29860-29863, 27120-27138, 27130/27132/27134/27137/27138, 29914-29916, 27299, 29999).
Check member's federal/state/contract terms for any exceptions or mandated coverage.

Denial Risk

Integral Procedure Denial Risk — Do Not Bill Separately

Iliopsoas tendon release, capsular repair, capsular release, and debridement during hip arthroscopy are considered integral to the primary hip procedure and are not separately reimbursable. Do not submit separate claims for these when billed as part of an included primary hip procedure.

Integral procedures include iliopsoas tendon release, capsular repair, capsular release.

Clinical Background

Femoroacetabular Impingement (FAI) results from abnormal bony morphology of the hip — commonly cam lesions (loss of femoral head sphericity/alpha angle elevation), pincer deformity (acetabular overcoverage), or a combined pattern. These morphologic changes produce repetitive contact between the femoral head–neck junction and the acetabular rim, often causing labral tears and progressive cartilage damage. Clinically, FAI is associated with groin pain, limited internal rotation, impaired function, and, in some patients, accelerated joint degeneration that may ultimately lead to osteoarthritis and need for total hip arthroplasty.

Terms and Thresholds

Femoroacetabular Impingement (FAI) Syndrome — definitions and types (cam, pincer, combined)

Definition of FAI SyndromeFAI occurs from hip formation abnormalities or bone overgrowth (bone spurs) causing abnormal contact between femoral head and acetabulum, leading to labral tears and cartilage breakdown.

Pincer typeAcetabular overcoverage (e.g., lateral center edge angle > 40°, coxa profunda, or acetabular retroversion) causing labral compression.

Cam typeLoss of femoral head sphericity with resultant bony prominence or alpha angle > 50°, causing femoral head to grind acetabular cartilage.

Combined (mixed) typeBoth pincer and cam morphological features are present.

Disabling Pain / Functional Disability / PROMs — WOMAC, HOOS, iHOT-33 thresholds

Disabling pain (WOMAC)