Highmark Commercial Medical Policy - Pennsylvania

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Medical Policy: S-176-007
Topic: Hip Arthroscopies
Section: Surgery
Effective Date: October 10, 2016
Issue Date: June 25, 2018
Last Reviewed: June 2018

Hip arthroscopy refers to the viewing of the interior of the acetabulofemoral (hip) joint through an arthroscope and the treatment of hip pathology through a minimally invasive approach.

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Policy Position Coverage is subject to the specific terms of the member’s benefit plan.

Arthroscopic treatment of the following conditions may be considered medically necessary when ALL of the following criteria for each condition have been met.

For femoroacetabular impingement (FAI)

  • Adolescent patients should be skeletally mature with documented closure of growth plates (e.g., 15 years or older); or
  • Adult patients should be younger than 55 years of age; and
  • Moderate-to-severe hip pain that has worsened by flexion activities (e.g., squatting or prolonged sitting) that significantly limits activities; and
  • Unresponsive to conservative therapy for at least 3 months (including activity modifications, restriction of athletic pursuits and avoidance of symptomatic motion); and
  • Positive impingement sign on clinical examination (pain elicited with 90 degrees of flexion and internal rotation and adduction of the femur); and


  • Morphology indicative of cam or pincer-type FAI, e.g., pistol-grip deformity, femoral head-neck offset with an alpha angle greater than 50 degrees, a positive wall sign, acetabular retroversion (over-coverage with crossover sign), coxa profunda or protrusion, or damage of the acetabular rim; and
  • High probability of a causal association between the FAI morphology and damage, e.g., a pistol-grip deformity with a tear of the acetabular labrum and articular cartilage damage in the anterosuperior quadrant; and
  • No evidence of advanced osteoarthritis, defined as Tonnis grade II or III, or joint space of less than 2mm; and
  • No evidence of severe (Outerbridge grade IV) chondral damage.

Arthroscopic treatment of FAI in all other situations is considered experimental/investigational and therefore non-covered. There is inadequate scientific evidence in peer-reviewed medical literature demonstrating the effectiveness of arthroscopic treatment of FAI in all other situations.

Procedure Codes
29914, 29915

For labral tears of the hip
Arthroscopic treatment of labral tears of the hip maybe considered medically necessary when:

  • A symptomatic tear has been confirmed by MR arthrogram without associated cartilage or bony pathologies, and
  • Conservative treatments (such rest, anti-inflammatory medication or physical therapy) have failed after a 4 to 6 week trial.

Arthroscopic treatment of labral tears of the hip in all other situations is considered experimental/investigational and therefore non-covered. There is inadequate scientific evidence in peer-reviewed medical literature demonstrating the effectiveness of arthroscopic treatment of labral tears of the hip in all other situations.

Procedure Codes

Place of Service: Inpatient

The policy position applies to all commercial lines of business

Denial Statements

Services that do not meet the criteria of this policy will be considered experimental/investigational (E/I). A network provider can bill the member for the experimental/investigational service. The provider must give advance written notice informing the member that the service has been deemed E/I. The member must be provided with an estimate of the cost and the member must agree in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.


Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as:
    • Qualified interpreters
    • Information written in other languages
If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

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