DraftUnitedHealthcarePolicy CSOS6TN.U

Surgery of the Hip (for Tennessee Only)

Medical policy governing surgical treatment of the hip, including arthroscopy and arthroplasty, for Medicaid and CoverKids members in Tennessee.

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Hip (for Tennessee Only)

Policy CodePolicy CSOS6TN.U

Change TypeMaterial update — documentation requirement added

Effective DateSep 1, 2025

Next Review DateN/A

Key ActionProvide medical records documentation on request to show the member meets InterQual hip clinical criteria for coverage.

SourceLink

POLICY UPDATE CHANGES

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

Benefit coverage is governed by federal, state, or contractual requirements which may differ from the standard benefit plan.

Tennessee-onlyapplicability

InterQual referenceduses InterQual

Tonnis 2-3OA exclusion

Outerbridge III-IVSevere cartilage exclusion

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

29 studiesHRQL studies

Coverage Criteria for Hip Surgery

Coverage for Surgical Treatment of FAI

Covered when ALL of the following are met:

Primary coverage logic: Surgery of the hip (including arthroscopy and arthroplasty) is considered medically necessary in certain circumstances per InterQual Procedures: hip criteria.

Refer to InterQual CP: Procedures: hip for detailed clinical criteria and individual procedure indications.

Evidence-based coverage considerations

Evidence summary and considerations to inform clinical judgment and coverage decisions:

Evidence considerations: Randomized trials and meta-analyses show arthroscopy can improve certain patient-reported outcomes (for example, iHOT-33 at 12 months) compared with nonoperative care, but results vary by instrument and follow-up; long-term comparative data are insufficient to conclude superiority or prevention of progression to arthroplasty.

Limitations include small number of RCTs, heterogeneity of physiotherapy protocols, short follow-up, and predominance of cam morphology in study cohorts.

Impact of osteoarthritis: Presence of radiographic osteoarthritis is associated with higher failure rates and substantially higher rates of conversion to total hip arthroplasty after surgical management (pooled conversion 37.3% with OA vs 9.7% without OA).

Radiographic OA (eg, Tonnis Grade 2–3, Kellgren-Lawrence grade 3–4) and severe cartilage damage (Outerbridge Grade III–IV) are negative prognostic factors and should be considered when assessing expected benefit.

Outcome measures: Different outcome measures (iHOT-33, HOOS, mHHS, NAHS, EQ-VAS) show inconsistent differences between arthroscopy and conservative care across studies and timepoints; many series report improvements in generic and hip-specific HRQL between 12 and 24 months postoperatively in patients without advanced OA.12–24 months

MCID and PASS relationships to clinical benefit are uncertain; subjective improvement may not align with score changes.

Surgical treatment for Femoroacetabular Impingement (FAI) Syndrome is considered not medically necessary when there is evidence of advanced osteoarthritis (Tonnis Grade 2 or 3) and/or severe cartilage damage (Outerbridge Grade III or IV). The policy specifies these radiographic and intraoperative grading thresholds as exclusionary findings when assessing medical necessity for FAI surgical procedures.

Significant radiographic osteoarthritic changes (for example, Kellgren‑Lawrence grade 3–4) and advanced degenerative joint findings are also identified as negative prognostic factors and support a determination of noncoverage for arthroscopic management of FAI.

For informational purposes only: FDA approval alone is not a basis for coverage. Surgical procedures themselves are not regulated by the U.S. Food and Drug Administration; however, devices and instruments used during hip surgery may require FDA clearance or approval. FDA regulatory status of devices does not, by itself, establish medical necessity or guarantee coverage.

Restating the policy exclusion: surgical treatment of FAI is regarded as unproven and not medically necessary when Tonnis Grade 2 or 3 osteoarthritis or Outerbridge Grade III or IV cartilage damage is present. These specific grade thresholds should be used when evaluating eligibility for operative interventions for FAI.

Evidence limitations: available randomized trials and meta-analyses report that arthroscopic hip surgery can improve certain patient-reported outcomes (for example, iHOT‑33 at 12 months) compared with nonoperative care, but results vary by outcome instrument and timepoint. The body of evidence is limited by a small number of RCTs, heterogeneous nonoperative protocols, and generally short follow-up.

Long-term comparative data are insufficient to conclude that arthroscopy provides superior or durable benefits over nonoperative therapy or prevents progression to total hip arthroplasty. These evidence gaps create uncertainty about long‑term superiority and durability of benefit following hip arthroscopy for FAI.

Procedure and Coding References

Arthroscopy, Arthrotomy, Hemiarthroplasty (listed)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).
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

Total Joint Replacement and Revisions (listed)CPT/HCPCS

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

FDA/regulatory notesinformational

No codes listed

Alpha angle — definition and threshold

DefinitionAlpha angle quantifies cam morphology; radiographic evidence of cam-type FAI includes an alpha angle greater than 50 degrees.

Numeric threshold> 50 degrees

Clinical implicationAlpha angle >50° indicates loss of sphericity of the femoral head and supports cam-type FAI diagnosis, which may be considered when evaluating surgical indications.

Lateral center edge angle — definition and threshold

DefinitionLateral center edge angle (LCEA) quantifies acetabular overcoverage; radiographic evidence of pincer-type FAI includes a lateral center edge angle greater than 40 degrees.

Numeric threshold

Provider Requirements and Operational Notes

Prior Authorization

Prior Authorization — InterQual referenced

InterQual Procedures: hip criteria are referenced and will be used for medical necessity determinations for hip surgical procedures (see Coverage Rationale). Providers should reference InterQual when preparing prior authorization requests.

InterQual Procedures: hip (Arthroscopy, Hemiarthroplasty, Total Joint Replacement, Arthrotomy, Removal/Replacement TJR)

Documentation Required

Documentation Required for Review

Benefit coverage is governed by applicable federal, state, and contractual requirements. Medical records documentation may be required to assess whether the member meets clinical criteria for coverage and must be provided when requested. Submission of records does not guarantee coverage.

Medical records may be requested to verify clinical criteria and key findings (imaging, operative notes, conservative therapy trials).
Absence of required documentation may lead to denial or delay of authorization/coverage.

Clinical Background and Definitions

Femoroacetabular impingement (FAI) arises from abnormal bony morphology that produces pathologic contact between the femoral head–neck junction and the acetabular rim. The major morphological patterns are cam (aspheric femoral head/neck prominence), pincer (acetabular overcoverage), or a combined cam‑pincer deformity.

This abnormal contact can cause labral tears and progressive articular cartilage injury, leading to groin pain, reduced internal rotation, mechanical symptoms, and functional limitation. Radiographic criteria used to identify FAI include measurements such as an alpha angle > 50 degrees for cam morphology and a lateral center‑edge angle > 40 degrees for pincer morphology.

Key Definitions and Outcome Measures

FAI Syndrome — definition and morphology subtypes

Syndrome definitionFemoroacetabular Impingement (FAI) Syndrome: abnormal femoral head and/or acetabular morphology producing abnormal contact, labral tears, and cartilage breakdown leading to pain, limited internal rotation, and functional impairment.

Cam morphologyCam: loss of sphericity of the femoral head with resultant bony prominence; radiographic criterion includes alpha angle >50°.

Pincer morphologyPincer: acetabular overcoverage (e.g., lateral center edge angle >40°, coxa profunda, acetabular retroversion) causing labral crushing under the rim.

Combined (mixed)Combined impingement: presence of both cam and pincer features on imaging.

Patient-reported outcome (PRO) measures and thresholds

WOMAC — description

Policy History and Revisions

2025-09-01revisionLatest

Added language clarifying that benefit coverage is determined by federal, state, or contractual requirements and that medical records documentation may be required to assess whether the member meets clinical criteria for coverage (documentation does not guarantee coverage); archived previous policy version CSOS6TN.T.

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Hip (for Tennessee Only)

Policy CodePolicy CSOS6TN.U

Change TypeMaterial update — documentation requirement added

Effective DateSep 1, 2025

Next Review DateN/A

Key ActionProvide medical records documentation on request to show the member meets InterQual hip clinical criteria for coverage.

SourceLink

On This Page

Clinical implicationLCEA >40° indicates acetabular overcoverage (pincer morphology) such as coxa profunda or retroversion and may support consideration of surgical correction when clinical criteria are met.

Follow-up timepoints reported in studies

Common study follow-up timepoints6 months

Common study follow-up timepoints12 months

Common study follow-up timepoints24 months

Note

Provider Action — Nonoperative Therapy Expectation

Nonoperative therapy (for example, physiotherapy) is recommended as first-line management for femoroacetabular impingement (FAI). Randomized controlled trials comparing arthroscopy versus physiotherapy show some short- to mid-term advantages for arthroscopy but limitations in sample size and follow-up exist; therefore prior authorization decisions should document a trial of appropriate nonoperative care when clinically appropriate.

Document duration and type of physiotherapy or other nonoperative measures tried prior to surgery when applicable.
If nonoperative therapy was not attempted, include clinical rationale in the submission.

Denial Risk

Denial Risk — Advanced Osteoarthritis / Severe Cartilage Damage

Surgical treatment is NOT considered medically necessary in the presence of advanced osteoarthritis or severe cartilage damage. Explicit documentation of imaging and grading is required to support coverage decisions.

Denial risk when Tonnis Grade 2-3 osteoarthritis is documented.
Denial risk when Outerbridge Grade III-IV cartilage damage is documented.

Documentation Required

Provider Action — Complete Documentation Required

Lack of required medical records or insufficient documentation of conservative therapy, imaging findings, or clinical criteria may result in denial or delay of coverage. Provide complete clinical notes, imaging reports with grading (Tonnis/Outerbridge where applicable), and documentation of nonoperative therapy or rationale for proceeding directly to surgery.

Include imaging reports with explicit Tonnis and/or Outerbridge grades when available.
Include physical exam findings, symptom duration, and details of nonoperative therapy trials.
Failure to submit requested records may lead to an adverse determination.

Western Ontario and McMaster Universities Arthritis Index (WOMAC): disease-specific, self-administered questionnaire with domains for pain, stiffness, and physical function.

WOMAC — disabling pain/functional disability thresholdDisabling pain or functional limitation defined as WOMAC domain score >40.

HOOS — descriptionHip Dysfunction and Osteoarthritis Outcome Score (HOOS): 43-item self-administered hip-specific questionnaire covering pain, symptoms, activities of daily living, sport/recreation, and hip-related quality of life.

iHOT-33 — descriptionInternational Hip Outcome Tool (iHOT-33): 33-item PROM for hip disorders with four subscales (symptoms/function, sport, job, social/emotional); scores range 0–100 per item and final score is averaged over 33 items.

OA and cartilage grading systems referenced

Outerbridge gradingOuterbridge cartilage grades I–IV: Grade I softening/swelling; Grade II partial-thickness defect; Grade III fissuring to subchondral bone (>1.5 cm); Grade IV exposed subchondral bone.

Tonnis classificationTonnis grades 0–3: Grade 0 no OA; Grade 1 slight changes; Grade 2 moderate joint space narrowing and loss of sphericity; Grade 3 severe joint space narrowing, large cysts, deformity.

Kellgren-LawrenceKellgren-Lawrence grade 3–4 denotes significant radiographic OA (grade 3: definite narrowing and moderate osteophytes; grade 4: large osteophytes, marked narrowing, severe sclerosis and deformity).

Radiographic OA — prognostic associations

Prognostic associationPresence of radiographic osteoarthritis (OA) is correlated with higher failure rates and worse outcomes after surgical management of FAI.

Conversion to THA — pooled ratesRate of conversion to total hip arthroplasty was significantly higher with radiographic OA: 37.3% in FAI with OA vs 9.7% in FAI without OA.

Clinical implicationRadiographic OA should be considered a negative prognostic factor when assessing expected benefit from FAI surgery and may support noncoverage per policy exclusions.

Validated PROMs and comparative findings

Validated PROMs used in studiesiHOT-33, HOOS, modified Harris Hip Score (mHHS), and Non-Arthritic Hip Score (NAHS) are commonly used across trials and meta-analyses to measure outcomes.

Comparative findingsStudies show mixed and instrument-dependent results: e.g., iHOT-33 favored arthroscopy at 12 months while other measures (HOOS, mHHS, NAHS) often showed no significant difference.

Interpretation cautionDifferences across instruments and short follow-up limit conclusions; MCID/PASS relationships to clinical benefit are uncertain and long-term superiority is not established.