CurrentUnitedHealthcarePolicy CSOS6KY.10

Surgery of the Hip (Kentucky)

This policy governs medical necessity and coverage guidance for hip surgical procedures, including arthroscopy and total hip arthroplasty, for UnitedHealthcare members in Kentucky.

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Hip (Kentucky)

Policy CodePolicy CSOS6KY.10

Change TypeAdded documentation language

Effective DateAug 1, 2025

Next Review Date

Key ActionProvide medical records documentation when requesting prior authorization to demonstrate that InterQual clinical criteria are met.

SourceLink

POLICY UPDATE CHANGES

Medical Records Documentation Used for Reviews language added clarifying that documentation may be required to assess clinical criteria but does not guarantee coverage.

InterQualprimary clinical criteria source referenced

CPT 29860-29916, 27120-27138, 27299, 29999, S2118example procedure codes listed

Kentucky-onlystate applicability

WOMAC, HOOS, iHOT-33, Outerbridge, Kellgren-Lawrence, Tonniskey outcome scores and classifications defined

Coverage Criteria

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InterQual-based medical necessity

Covered when InterQual surgical procedure-specific criteria are met.

InterQual adherence: Provider must meet the applicable InterQual Procedures criteria for the specific hip surgery (e.g., diagnostic arthroscopy, surgical arthroscopy, arthrotomy, hemiarthroplasty, total joint replacement, revisions).See InterQual

UnitedHealthcare uses InterQual as the primary medical/surgical criteria source; exact decision logic and detailed clinical requirements are in the referenced InterQual criteria.

The listing of procedure or diagnosis codes in this policy is provided for reference only. Listing of a code does not imply that the service described by the code is a covered or non‑covered health service; actual coverage and reimbursement are determined by the member‑specific benefit plan document and applicable laws.

This policy does not attempt to enumerate every intervention that may be considered not medically necessary. Coverage determinations depend on the applicable InterQual clinical criteria for the procedure and the member‑specific benefit plan; an intervention not described here may still be non‑covered under a particular benefit or law.

Coding

Principal hip surgery CPT codesCPTCovered

29860	Arthroscopy, diagnostic with or without synovial biopsy (hip)
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
27125	Hemiarthroplasty, hip, partial
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

1–10 of 11

1/2

FAI-specific and unlisted/HCPCS codesmixedCovered

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
S2118	Metal-on-metal total hip resurfacing, including acetabular and femoral components

WOMAC pain domain — > 40

DefinitionWOMAC pain domain score greater than 40 (Disabling Pain)

Source study/referenceQuintana, 2009 as cited in policy definitions

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

WOMAC functional limitation domain — > 40

DefinitionWOMAC functional limitation domain score greater than 40 (Functional Disability)

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

Source study/referenceQuintana, 2009 as cited in policy definitions

Provider Actions & Authorization

Prior Authorization

InterQual-based prior authorization

Prior authorization decisions for the hip surgeries listed in InterQual Procedures are referenced to InterQual clinical criteria. Providers should follow InterQual guidance when submitting requests for: Arthroscopy (diagnostic and surgical) of the hip, arthrotomy, hemiarthroplasty, total hip replacement, and related hip procedures.

Affected procedures: hip arthroscopy, arthrotomy, hemiarthroplasty, total hip replacement

Note

Prior authorization required

Prior authorization requirement: submit a prior authorization request when seeking coverage for the listed hip surgical procedures. Follow the payer’s prior authorization submission processes and timelines.

Documentation Required

Medical records documentation may be requested

Medical records documentation may be required to determine whether the member meets the clinical criteria for coverage. Documentation requests do not guarantee coverage — coverage is determined by applicable federal, state, or contractual requirements and the clinical criteria.

Documentation may include: relevant clinic notes, imaging reports, operative notes, prior conservative treatment records, and InterQual-related documentation

Denial Risk

Documentation-related denial risk

Failure to provide requested medical records or required documentation may result in denial of the prior authorization request. It is the provider’s responsibility to supply complete records to support medical necessity per the InterQual criteria and applicable benefit terms.

Providers are responsible for submitting sufficient documentation to avoid denial

Background

Femoroacetabular impingement (FAI) is a hip condition caused by abnormal bony morphology (cam, pincer, or combined) that produces atypical contact between the femoral head/neck and the acetabulum, which can lead to labral tears, cartilage damage, pain, stiffness, and limited range of motion. Surgical options range from arthroscopic procedures—such as femoroplasty, acetabuloplasty, and labral repair—to open arthrotomy and joint replacement procedures, and selection of surgery is guided by validated outcome measures and radiographic classifications.

This policy uses InterQual Procedures as the primary clinical criteria source to determine medical necessity for hip surgical procedures. Validated outcome instruments referenced in the clinical context include the WOMAC (with Disabling Pain defined as WOMAC pain domain > 40), the HOOS, and the iHOT‑33, and radiographic severity is characterized using classifications such as Outerbridge, Kellgren‑Lawrence, and Tonnis.

Definitions and Clinical Measures

Disabling Pain (WOMAC) — WOMAC pain domain > 40

Operational thresholdDisabling Pain defined as WOMAC pain domain > 40

Use in policyApplied as a clinical threshold to identify disabling hip pain for surgical consideration

Instrument detailsPart of the WOMAC 24‑item questionnaire assessing pain, stiffness, and function

Functional Disability (WOMAC) — WOMAC functional limitation domain > 40

Operational thresholdFunctional Disability defined as WOMAC functional limitation domain > 40

Use in policyApplied as a clinical threshold to identify functional impairment for surgical consideration

Instrument detailsWOMAC functional limitation domain is part of the WOMAC 24‑item instrument

FAI Syndrome — cam/pincer/combined morphology causing abnormal contact

DefinitionFemoroacetabular Impingement (FAI) Syndrome: hip condition caused by abnormal bony morphology (cam, pincer, or combined) that produces abnormal contact between the femoral head/neck and acetabulum, potentially leading to labral tears and cartilage damage

Cam morphologyLoss of sphericity of the femoral head with resultant bony prominence (femoral head not round) causing grinding of acetabular cartilage

Pincer morphologyOvercoverage of the femoral head by the acetabulum with extra bone along the rim, causing labral crushing under the rim

Combined morphologyPresence of both cam and pincer features concurrently (mixed impingement)

HOOS — 43-item hip-specific questionnaire

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

Item count43 questions

SubscalesPain; symptoms; function in daily living; sport and recreation; hip‑related quality of life

iHOT-33 — 33-item patient-reported outcome for hip disorders

DefinitionInternational Hip Outcome Tool (iHOT‑33): 33‑item patient‑reported outcome measure for hip disorders with four subscales (Symptoms, Sport, Job, Social) scored 0–100 per item and averaged

Item count33 items

ScoringEach item scored 0–100; final score is the sum divided by 33

Outerbridge / Kellgren-Lawrence / Tonnis — Radiographic classification thresholds

Radiographic classifications indicating moderate–severe diseaseKellgren‑Lawrence grade 3–4 or Tonnis grade 2–3 indicate moderate to severe osteoarthritis

Outerbridge gradingOuterbridge grades I–IV describe cartilage lesions (Grade III: fissuring to subchondral bone >1.5 cm; Grade IV: exposed subchondral bone)

Kellgren‑Lawrence detailsGrade 3: definite joint space narrowing, moderate osteophytes, some sclerosis, possible deformity; Grade 4: large osteophytes, marked joint space narrowing, severe sclerosis, definite bone deformity

Tonnis detailsGrade 2: moderate joint space narrowing and loss of head sphericity; Grade 3: severe joint space narrowing, large cysts, severe deformity

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