CurrentUnitedHealthcarePolicy CS056KS.04

Surgery of the Hip (for Kansas Only)

Defines medical necessity and coverage guidance for hip surgery, including surgical treatment of Femoroacetabular Impingement (FAI) Syndrome, for UnitedHealthcare members in Kansas; applies to providers requesting coverage for hip procedures.

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Hip (for Kansas Only)

Policy CodePolicy CS056KS.04

Change TypeDefinitions and coding clarifications

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionSubmit documentation demonstrating the member meets InterQual procedural criteria for the requested hip procedure.

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.

References section updated to reflect the most current information.

InterQualPrimary clinical criteria source

29860–29916, 27120–27138Example procedure codes listed

KansasApplies to

>40

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Coverage Criteria

InterQual-based Medical Necessity

Covered when ALL of the following are met per InterQual procedural criteria

InterQual-based coverage: Surgery of the hip and surgical treatment for Femoroacetabular Impingement (FAI) Syndrome are considered proven and medically necessary in certain circumstances when the member meets the applicable InterQual CP: Procedures for the requested intervention (e.g., Arthroscopy, Diagnostic +/- Synovial Biopsy, Hip; Arthroscopy, Surgical, Hip; Arthroscopy, Surgical, Hip (Pediatric); Arthrotomy, Hip; Hemiarthroplasty, Hip; Total Joint Replacement (TJR), Hip; Removal and Replacement, Total Joint Replacement, Hip).See InterQual CP: Procedures listed in policy

Providers must reference and document the specific InterQual procedural criteria that are met for the requested hip procedure; documentation must be available for review.

Note: iliopsoas tendon release, capsular repair, capsular release, and debridement during hip arthroscopy are considered integral to the primary hip procedure when performed in conjunction with the primary procedure codes listed in this policy and are not separately reimbursable.

The lists of procedure and diagnosis codes in this policy are provided for reference only. Listing a code does not by itself imply the service is a covered health service or guarantee reimbursement; benefit coverage is determined by applicable federal, state, contractual requirements, and other policies that may apply.

Coding and Procedure Codes

Arthroscopy and arthroplasty codes (part 1)CPT

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).

Arthroplasty and FAI-related codes (part 2)CPT

27132	Conversion of previous hip surgery to total hip 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 allograft.
27299	Unlisted procedure, pelvis or hip joint.
29914	Arthroscopy, hip, surgical; with femoroplasty (i.e., treatment of cam lesion).

FAI and resurfacing codes (part 3)mixed

29915	Arthroscopy, hip, surgical; with acetabuloplasty (i.e., treatment of pincer lesion).
29916	Arthroscopy, hip, surgical; with labral repair.
29999	Unlisted procedure, arthroscopy.
S2118	Metal-on-metal total hip resurfacing, including acetabular and femoral components.

inv-07: WOMAC pain domain

WOMAC pain domain> 40

MeasureWestern Ontario and McMaster Universities Arthritis Index (WOMAC) – pain domain

Source/referenceQuintana, 2009 (as cited in policy)

inv-08: WOMAC functional limitation domain

WOMAC functional limitation domain> 40

MeasureWestern Ontario and McMaster Universities Arthritis Index (WOMAC) – functional limitation domain

Provider Actions and Requirements

Prior Authorization

InterQual-based prior authorization

Coverage determinations for requests are evaluated against InterQual procedural criteria and required documentation. Prior authorization decisions should reference the InterQual CP procedures listed in the policy (e.g., Arthroscopy, Diagnostic +/- Synovial Biopsy, Hip; Arthroscopy, Surgical, Hip; Arthrotomy, Hip; Hemiarthroplasty, Hip; Removal and Replacement, Total Joint Replacement (TJR), Hip; Total Joint Replacement (TJR), Hip). Ensure submitted records demonstrate that the member meets the applicable InterQual procedural criteria.

InterQual CP: Procedures (hip arthroscopy/arthrotomy/arthroplasty criteria)

Note

Conservative treatment assessment

Assessment of prior conservative management should align with InterQual expectations — documentation should show that nonoperative therapies were attempted and optimized as indicated by the InterQual procedural criteria before surgical intervention is approved.

Conservative treatments may include: physical therapy, activity modification, NSAIDs, intra‑articular injections when appropriate

Background

Femoroacetabular Impingement (FAI) Syndrome is a structural hip disorder (pincer, cam, or combined) in which abnormal contact between the femoral head/neck and the acetabulum can cause labral tears, progressive cartilage damage, and symptoms such as hip pain, stiffness, reduced range of motion, and limp. Assessment incorporates patient-reported outcome measures (for example, WOMAC, HOOS, iHOT-33) and radiographic findings; specific radiographic thresholds referenced in this policy include alpha angle > 50 degrees and lateral center edge angle > 40 degrees. Surgical treatment for FAI (including diagnostic or surgical hip arthroscopy, femoroplasty, acetabuloplasty, and labral repair) is considered when patients meet the InterQual procedural criteria and documented clinical severity.

Definitions and Outcome Measures

inv-16: Disabling Pain (WOMAC)

Disabling Pain (WOMAC)WOMAC pain domain > 40

InstrumentWestern Ontario and McMaster Universities Arthritis Index (WOMAC) – pain domain

ReferenceQuintana, 2009 (as cited in policy)

inv-17: Functional Disability (WOMAC)

Functional Disability (WOMAC)WOMAC functional limitation domain > 40

InstrumentWestern Ontario and McMaster Universities Arthritis Index (WOMAC) – functional limitation domain

Reference

Revision History

2026-04-01revisionLatest

Updated definition of 'Radiographic Findings of Osteoarthritis'.

2026-04-01clarification

Clarified that iliopsoas tendon release, capsular repair, and capsular release 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 therefore not separately reimbursable.

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Hip (for Kansas Only)

Policy CodePolicy CS056KS.04

Change TypeDefinitions and coding clarifications

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionSubmit documentation demonstrating the member meets InterQual procedural criteria for the requested hip procedure.

SourceLink

On This Page

Quintana, 2009 (as cited in policy)

inv-09: Alpha angle

Alpha angle> 50 degrees

RelevanceRadiographic criterion for Cam-type FAI (loss of femoral head sphericity or bony prominence)

Source/referenceWitstein et al.; Pun et al., as cited in policy

inv-10: Lateral center edge angle

Lateral center edge angle> 40 degrees

RelevanceRadiographic criterion for Pincer-type FAI (overcoverage of the femoral head)

Source/referenceWitstein et al.; Pun et al., as cited in policy

Documentation Required

Required medical record documentation

The patient's medical record must contain documentation that fully supports medical necessity. Required items include a clear history, focused physical examination, and results of pertinent diagnostic tests or procedures. Provide legible records and make them available upon request.

History: symptom onset, duration, prior conservative therapies and response, prior diagnostic or therapeutic procedures
Physical exam: focused hip exam findings (range of motion, impingement signs, gait, neurovascular status)
Diagnostic tests: relevant imaging reports (e.g., radiographs, MRI), lab results if applicable, operative notes from prior procedures

Denial Risk

Documentation insufficiency — denial risk

Incomplete or insufficient medical records may delay review or result in denial of the request. Lack of documentation demonstrating prior conservative management, exam findings, or pertinent diagnostic results that match InterQual criteria is a common reason for denial.

Denial risk if records do not document conservative therapy attempts or clinical findings required by InterQual
Denial risk if imaging/diagnostic results or operative reports are missing or illegible

Quintana, 2009 (as cited in policy)

inv-18: FAI Syndrome definition

FAI Syndrome typesPincer, Cam, or Combined (Mixed)

Pincer descriptionExtra bone extends over the acetabular rim causing labral crushing; radiographic findings may include lateral center edge angle > 40, coxa profunda, or acetabular retroversion

Cam descriptionLoss of femoral head sphericity with a bony prominence (alpha angle > 50) causing cartilage damage and labral tears

Labral pathologyLabral tears are commonly associated with FAI and may result from abnormal bone contact

inv-19: HOOS — Hip Dysfunction and Osteoarthritis Outcome Score definition

HOOS (Hip Dysfunction and Osteoarthritis Outcome Score)43-item self-administered hip-specific questionnaire with five subscales: pain, symptoms, function in daily living, function in sport/recreation, and hip-related quality of life

PurposeEvaluates symptoms and functional limitations; commonly used to assess interventions in hip dysfunction or osteoarthritis

ReferenceNilsdotter, 2011 (as cited in policy)

inv-20: iHOT-33 — International Hip Outcome Tool definition

iHOT-33 (International Hip Outcome Tool)33-item PROM with four subscales: Symptoms (16 items), Sport (6 items), Job (4 items), Social (7 items); items scored 0–100 and final score is sum divided by 33

UseReference PROM for assessing people with hip disorders including FAI Syndrome

ReferenceBissani Gasparin et al., 2022 (as cited in policy)