CurrentUnitedHealthcarePolicy CS056KY.13

Surgery of the Hip (for Kentucky Only)

Defines UnitedHealthcare coverage policy for surgical treatment of the hip, including femoroacetabular impingement (FAI) procedures, for members in Kentucky.

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Hip (for Kentucky Only)

Policy CodePolicy CS056KY.13

Change TypeMaterial and non-material revisions

Effective DateApr 1, 2026

Next Review Date

Key ActionObtain applicable prior authorization per plan and InterQual for listed hip procedures.

SourceLink

POLICY UPDATE CHANGES

Updated definition of 'Radiographic Findings of Osteoarthritis'.

Revised description for CPT codes 27299 and 29999 under Femoroacetabular Impingement (FAI) Syndrome.

Updated References section to reflect the most current information and archived previous policy version CS056KY.12.

KentuckyApplicable state

CS056KY.13Policy identifier

InterQualPrimary clinical source

CPT/HCPCSProcedure codes

Coverage Criteria

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InterQual-based surgical coverage

Covered when ALL of the following apply per InterQual criteria:

InterQual-based coverage: Clinical coverage criteria for specific hip surgeries are determined by the referenced InterQual CP modules (Arthroscopy, Diagnostic; Arthroscopy, Surgical; Arthrotomy; Hemiarthroplasty; Removal and Replacement TJR; Total Joint Replacement).

Provider must reference the applicable InterQual module for procedure-specific inclusion/exclusion and detailed clinical criteria; benefit plan, federal, state, or contractual requirements govern in case of conflict.

The list of procedure and diagnosis codes included in this policy is provided for reference only. Listing of a code does not imply the service described by the code is covered or reimbursable under a member’s benefit plan. Benefit coverage is determined by applicable federal, state, and contractual requirements and laws, and other policies and guidelines may apply. Providers should confirm coverage and reimbursement under the member’s specific plan before delivering services.

Coding and Diagnostic Thresholds

Hip arthroscopy and arthroplasty CPT codesCPT

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), with or without autograft or allograft.
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.

1–10 of 11

1/2

FAI-specific and unlisted CPT codesCPT

27299	Unlisted procedure, pelvis or hip joint.
29914	Arthroscopy, hip, surgical; with femoroplasty (i.e., treatment of cam lesion).
29915	Arthroscopy, hip, surgical; with acetabuloplasty (i.e., treatment of pincer lesion).
29916	Arthroscopy, hip, surgical; with labral repair.
29999	Unlisted procedure, arthroscopy.

HCPCSHCPCS

S2118

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

WOMAC pain and function thresholds

WOMAC pain thresholdWOMAC pain domain > 40 (Disabling Pain)

WOMAC function thresholdWOMAC functional limitation domain > 40 (Functional Disability)

Instrument descriptionWOMAC: 24-item self-administered questionnaire with pain, stiffness, and physical function domains

Radiographic alpha angle

Alpha angle thresholdAlpha angle greater than 50 degrees (indicative of cam morphology)

Clinical relevanceLoss of sphericity of the femoral head with resultant bony prominence consistent with cam-type FAI

Source examplesReferenced imaging criteria include alpha angle > 50 degrees (Witstein et al., 2024; Pun et al., 2015)

Lateral center edge angle

Lateral center edge angle thresholdLateral center edge angle greater than 40 degrees (indicative of pincer morphology)

Radiographic signOvercoverage of the femoral head by the acetabulum, e.g., coxa profunda or acetabular retroversion

Clinical contextFindings support diagnosis of pincer-type FAI when present on imaging

Provider Actions and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required per InterQual criteria for hip surgeries and procedures listed in the policy (e.g., hip arthroscopy, arthrotomy, hemiarthroplasty, total joint replacement). Submit a prior authorization request before scheduling elective procedures.

Affected procedures: Arthroscopy (diagnostic/surgical), Arthrotomy, Hemiarthroplasty, Total Joint Replacement (Hip)
Reference InterQual® decision support during authorization review

Note

Provider Action: Submit Complete Documentation

Provide all requested supporting documentation promptly. Failure to supply required records may lead to delayed review or denial.

Make records legible and include relevant medical history, physical exam findings, and pertinent diagnostic test results
Include InterQual®-requested clinical information per the applicable procedure criteria

Documentation Required

Required Medical Records

The patient’s medical record must contain documentation that fully supports medical necessity for the requested service. Documentation may be requested and review is required to determine coverage; absence of adequate documentation may result in denial of the request.

Documentation includes, but is not limited to: relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures
Records must be maintained in the patient’s chart and made available upon request

Denial Risk

Documentation Supports Medical Necessity — Potential Denial Risk if Not Provided

If documentation does not clearly support the InterQual or contractual criteria, the service may be denied. Coverage decisions are governed by applicable federal, state, and contractual requirements which take precedence over standard policy guidance.

Denial risk if records do not demonstrate the InterQual criteria are met
Confirm benefit plan contractual/federal/state requirements prior to submission

Background

Femoroacetabular impingement (FAI) syndrome describes abnormal contact between the femoral head–neck junction and the acetabulum caused by congenital morphology or focal bone overgrowth, which can produce labral tears, chondral damage, and progressive osteoarthritis. FAI commonly presents in cam (femoral-sided), pincer (acetabular-sided), or combined morphologies, and is associated with groin pain, limited internal rotation, and activity-related functional impairment. Validated patient-reported outcome measures such as the WOMAC, HOOS, and iHOT-33 are referenced in this policy to quantify pain and functional impact when assessing candidacy for surgical intervention.

Definitions and Outcome Measures

Disabling Pain

DefinitionDisabling Pain: WOMAC pain domain > 40

Associated symptomsMay include pain and stiffness limiting activities and prompting consideration of surgical management when other criteria met

ReferenceQuintana, 2009 as cited in policy definitions

FAI Syndrome

DefinitionFemoroacetabular Impingement (FAI) Syndrome: abnormal contact from hip formation at birth or bone overgrowth causing labral tears and cartilage breakdown

TypesPincer, Cam, and Combined (Mixed)

Pincer radiographic criteriaOvercoverage of the femoral head; lateral center edge angle > 40 degrees, coxa profunda, or acetabular retroversion

Cam radiographic criteriaLoss of sphericity of the femoral head or alpha angle > 50 degrees

HOOS

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

UseCommonly used to evaluate interventions in individuals with hip dysfunction or hip osteoarthritis

Scoring domainsPain; Symptoms; Function in daily living; Function in sport and recreation; Hip-related quality of life

iHOT-33

iHOT-33 descriptionInternational Hip Outcome Tool (iHOT-33): 33-item PROM for hip disorders covering symptoms, sports, job, and social/lifestyle domains

SubscalesiHOT-Symptoms (16), iHOT-Sport (6), iHOT-Job (4), iHOT-Social (7)

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

Outerbridge Grades

Grade I–IV summaryOuterbridge Grades I–IV describe cartilage lesion severity from softening to exposed subchondral bone (Grade I: softening/swelling; II: partial-thickness defect ≤1.5 cm; III: fissuring to subchondral bone >1.5 cm; IV: exposed subchondral bone)

Grade 0Normal cartilage

Clinical implicationHigher grades indicate greater cartilage damage relevant to surgical decision-making

Tönnis Classification

Tönnis GradesTönnis Classification Grades 0–3 for radiographic osteoarthritis severity (Grade 0: no OA; Grade 1: slight changes; Grade 2: moderate changes with small cysts and moderate joint space narrowing; Grade 3: severe changes with large cysts and severe joint space narrowing)

Grade 0No signs of osteoarthritis

Grade 3Large cysts, severe joint space narrowing or obliteration, severe deformity of the head