ModifiedUnitedHealthcarePolicy CSOS6NM.C

Surgery of the Hip (for New Mexico Only)

Policy governing medical necessity and coverage for hip surgical procedures, including arthroscopy, hemiarthroplasty, arthrotomy, and total hip replacement, for UnitedHealthcare members in New Mexico.

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Hip (for New Mexico Only)

Policy CodePolicy CSOS6NM.C

Change TypeClarification / Non‑material edits

Effective DateAug 1, 2025

Next Review Date

Key ActionSubmit prior authorization with InterQual-based clinical criteria and include medical records documentation to demonstrate that the member meets coverage criteria.

SourceLink

POLICY UPDATE CHANGES

Medical Records Documentation Used for Reviews added language indicating documentation may be required to assess whether the member meets clinical criteria for coverage.

Statement clarifying that benefit coverage is determined by federal, state, or contractual requirements and applicable laws which may supersede the policy.

State-specificPolicy applies only to New Mexico

InterQualInterQual referenced

Tonnis 2–3Exclusion: advanced OA

Outerbridge III–IVExclusion: severe cartilage damage

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Procedure codes listed

Coverage and Medical Necessity Criteria

Medical necessity and exclusions for hip surgery

Covered when InterQual procedure-level criteria are met; specific exclusions apply for advanced degenerative changes.

InterQual-based medical necessity: Surgery of the hip (arthroscopy, diagnostic arthroscopy with or without synovial biopsy, pediatric hip arthroscopy, hemiarthroplasty, arthrotomy, and total joint replacement of the hip) is considered proven and medically necessary when documented clinical criteria from the applicable InterQual Procedure criteria are satisfied.Refer to InterQual CP: Arthroscopy (surgical and diagnostic), Hemiarthroplasty, Arthrotomy, Total Joint Replacement (Hip)

InterQual procedure criteria must be used to determine medical necessity for the listed hip procedures.

Exclusion for FAI surgical treatment: Femoroacetabular Impingement (FAI) surgical treatment (including arthroscopic correction) is unproven and NOT medically necessary in the presence of advanced osteoarthritis and/or severe cartilage damage.Tonnis Grade 2 or 3 OR Outerbridge Grade III or IV

Explicit denial condition; if either threshold is met, surgical FAI correction is not medically necessary.

Clinical evidence and considerations

Evidence summaries and limitations that inform coverage decisions for arthroscopic management of FAI.

Short-term outcome advantage: Randomized and comparative studies and meta-analyses report that arthroscopic surgery can provide superior patient-reported outcomes (for example, iHOT-33, HOOS, EQ-VAS) compared with physiotherapy/conservative care at approximately 12 months in some analyses, though improvement varies by outcome measure and timepoint.~12 months

Supported by meta-analyses and RCT data showing greater iHOT-33 improvement at 12 months (see Gatz et al. and pooled analyses).

Long-term outcomes uncertain: Long-term comparative data beyond ~24 months are limited; current evidence is insufficient to conclude that arthroscopic surgery prevents progression to total hip arthroplasty or provides durable superiority over nonoperative care.>24 months

Authors cite need for longer-term follow-up and more RCTs to evaluate prevention of joint degeneration.

Surgical treatment for Femoroacetabular Impingement (FAI) Syndrome is considered unproven and not medically necessary when there is evidence of advanced osteoarthritis (Tonnis Grade 2 or 3) or severe cartilage damage (Outerbridge Grade III or IV).

Surgeries of the hip are procedures and are not regulated by the U.S. Food and Drug Administration; information about FDA approval applies only to devices and instruments used during surgery and is provided for informational purposes. FDA approval alone is not a basis for coverage.

FAI surgical correction is contraindicated in the presence of advanced osteoarthritis (Tonnis Grade 2 or 3) and/or severe cartilage damage (Outerbridge Grade III or IV). When these findings are documented on imaging or intraoperative assessment, the procedure is considered not medically necessary and should not be performed for FAI correction.

Applicable Procedure and Severity Codes/Thresholds

Applicable CPT Codes - General 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, surgical; with synovectomy, hip
27120	Acetabuloplasty (e.g., Whitman, Colonna, Haygroves, or cup type)
27130	Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty)
27134	Revision of total hip arthroplasty; both components
27138	Revision of total hip arthroplasty; femoral component only

Applicable CPT/HCPCS Codes - FAI and Resurfacingmixed

27299	Unlisted procedure, pelvis or hip joint
29914	Arthroscopy, hip, surgical; with femoroplasty (i.e. treatment of cam lesion)
29915
29916	Arthroscopy, hip, surgical; with labral repair
29999	Unlisted procedure, arthroscopy
S2118	Metal-on-metal total hip resurfacing, including acetabular and femoral components

Radiographic and cartilage severity thresholds — alpha angle, lateral center edge angle, Outerbridge and Tonnis grades

Alpha angle (cam morphology)Alpha angle > 50° indicates cam-type impingement (loss of femoral head sphericity).

Lateral center edge angle (pincer morphology)Lateral center edge angle > 40° (or coxa profunda/acetabular retroversion) indicates pincer-type impingement/overcoverage.

Outerbridge cartilage gradesOuterbridge Grade III–IV denotes severe cartilage damage (Grade III: fissuring to subchondral bone >1.5 cm; Grade IV: exposed subchondral bone).

Tonnis radiographic OA gradesTonnis Grade 2–3 indicates moderate to severe radiographic osteoarthritis (Grade 2: moderate joint space narrowing; Grade 3: severe narrowing, large cysts/deformity).

Prior Authorization, Documentation, and Operational Notes

Prior Authorization

Prior Authorization Required

Prior authorization is required for the listed hip procedures and coverage determinations reference InterQual procedure-level criteria. Requests for arthroscopy or diagnostic hip procedures (including CPT codes such as 29860–29863, 29914–29916 and related hip procedure codes) must be submitted for prior authorization and will be reviewed using InterQual criteria for the relevant procedure. Prior authorization may require submission of medical records, imaging, and outcome measures to determine whether InterQual clinical criteria and conservative management steps have been met.

Prior authorization required for arthroscopy/diagnostic hip procedures per InterQual (e.g., CPT 29860–29863, 29914–29916, 27120, 27130, 27134, 27138)
Prior authorization/review may require submission of medical records, imaging, PROMs (e.g., iHOT-33, HOOS, WOMAC), and operative reports as applicable

Step Therapy

Nonoperative Therapy Considerations

Nonoperative therapy (including an adequate trial of physiotherapy and conservative management) should be documented and considered before authorization of arthroscopic surgical interventions for FAI. The evidence and InterQual guidance imply a trial of conservative care and appropriate timing; documentation of responses to nonoperative measures (duration, modalities, and functional outcome scores) supports medical necessity determinations.

Clinical Background

Femoroacetabular impingement (FAI) results from abnormal hip bony morphology — commonly cam (femoral head/neck asphericity), pincer (acetabular overcoverage), or a combined deformity — that produces abnormal contact between the femoral head–neck junction and the acetabular rim. This repetitive impingement can lead to labral tears, cartilage breakdown, progressive pain, stiffness, and restricted internal rotation. Surgical correction (for example, arthroscopic osteoplasty or labral repair) may improve symptoms in selected patients, but outcomes are poorer and the risk of conversion to total hip arthroplasty is higher when radiographic osteoarthritis or severe chondral damage is present.

Definitions and Outcome/Severity Measures

FAI Syndrome — definition of Femoroacetabular Impingement (FAI) Syndrome

DefinitionFemoroacetabular Impingement (FAI) Syndrome: hip pain and dysfunction from abnormal hip morphology (cam, pincer, or combined) causing abnormal contact, labral tears, cartilage breakdown, pain, stiffness, and limited internal rotation.

Cam-type featuresLoss of femoral head sphericity with alpha angle >50° due to a femoral head prominence (bone spur) causing impingement.

Pincer-type featuresAcetabular overcoverage (lateral center edge angle >40°, coxa profunda, or acetabular retroversion) leading to labral crushing and impingement.

Combined (mixed)Presence of both cam and pincer morphologies contributing to symptomatic impingement.

Outcome and severity measures — WOMAC, HOOS, iHOT-33, Outerbridge, Tonnis

WOMAC

Policy Changes and Notes

2025-08-01operational_updateLatest

Added language clarifying that medical records documentation may be required to assess whether a member meets clinical criteria for coverage, but that submission of records does not guarantee coverage; also clarified that benefit coverage is determined by federal, state, or contractual requirements and applicable laws.

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Hip (for New Mexico Only)

Policy CodePolicy CSOS6NM.C

Change TypeClarification / Non‑material edits

Effective DateAug 1, 2025

Next Review Date

Key ActionSubmit prior authorization with InterQual-based clinical criteria and include medical records documentation to demonstrate that the member meets coverage criteria.

SourceLink

On This Page

Effect of radiographic OA on outcomes:

Presence of radiographic osteoarthritis is associated with higher failure rates and increased conversion to total hip arthroplasty after arthroscopic treatment of FAI.

Radiographic OA present (e.g., Tonnis Grade >=2)

Meta-analyses demonstrated higher overall failure and higher conversion-to-THA rates in FAI patients with OA.

Benefit in patients without advanced OA: Arthroscopy can lead to significant improvements in generic and hip-specific health-related quality of life (eg, SF-12, EQ-5D, iHOT-33) at 12–24 months in patients who do not have advanced hip osteoarthritis.No advanced OA

Systematic reviews report consistent HRQL and hip-specific score improvements at 12–24 months in non-OA cohorts.

Heterogeneity and study limitations: Published studies have small sample sizes, heterogeneous nonoperative protocols, predominance of CAM morphology, variable outcome measures and follow-up durations, and inconsistent reporting of MCID and PASS, limiting generalizability.N/A

Limitations noted across reviews and trials; physiotherapy protocols and follow-up lengths vary and few studies extend beyond 24 months.

Documented trial of physiotherapy/rehabilitation and conservative measures prior to surgical authorization
Record duration and response to nonoperative care, including functional scores (WOMAC, HOOS, iHOT-33)

Documentation Required

Documentation and Denial Risk

Medical records and supporting documentation may be required for review and benefit determination. Lack of adequate documentation (including missing medical records, imaging, operative reports, or outcome measures) may result in delay or denial of the request. Benefit coverage is determined by applicable federal, state, or contractual requirements and submission of records does not guarantee coverage.

Medical records documentation may be requested to assess InterQual criteria and benefit eligibility
Incomplete or absent documentation may lead to denial or request for additional information
Benefit determination governed by federal/state/contractual requirements

Western Ontario and McMaster Universities Arthritis Index — disease-specific patient-reported instrument; 'Disabling pain' defined as WOMAC pain domain > 40.

HOOSHip Dysfunction and Osteoarthritis Outcome Score — 43-item hip-specific PROM assessing pain, symptoms, activities of daily living, sport/recreation, and quality of life.

iHOT-33International Hip Outcome Tool (iHOT-33) — 33-item PROM for young, active patients with hip disorders; scores reported as 0–100 per item and summed for overall score.

Outerbridge gradingCartilage damage grading from 0–IV used intraoperatively: Grade III (fissuring to subchondral bone >1.5 cm) and Grade IV (exposed subchondral bone) indicate severe cartilage loss.

Tonnis classificationRadiographic osteoarthritis grading (0–3); Grade 2 indicates moderate joint space narrowing and cysts, Grade 3 indicates severe joint space narrowing and deformity.

FAI (femoroacetabular impingement) — description of pathological hip morphology and management implications

Pathological morphologyFAI is a pathological hip morphology (cam, pincer, or mixed) where abnormal bone shape causes abnormal contact, labral tears, and cartilage breakdown that can produce pain and dysfunction.

Clinical consequencesOver time FAI may lead to labral tears, articular cartilage damage, pain, stiffness, and limited internal rotation, and is implicated in development of osteoarthritis.

Management implicationsManagement options include nonoperative care such as physiotherapy and operative correction (arthroscopic osteoplasty, labral repair); patient selection affects outcomes, with better results in patients without advanced OA.

Evidence noteRCTs and meta-analyses show arthroscopy can improve PROMs at ~12 months versus physiotherapy for selected patients, but long-term benefits and prevention of OA progression remain uncertain.

Radiographic osteoarthritis (OA) — relation to surgical failure and conversion to total hip arthroplasty

Association with surgical failureRadiographic osteoarthritis is associated with higher overall failure rates after arthroscopic management of FAI (pooled analyses showed higher failure in FAI with OA groups).

Conversion to total hip arthroplastyPatients with radiographic OA have significantly higher rates of conversion to total hip arthroplasty (FAI with OA: 37.3% vs FAI without OA: 9.7% in pooled analysis).

Impact on outcomesPresence of radiographic OA correlates with worse pain and function outcomes after surgical management of FAI compared with patients without radiographic OA.