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.

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

Imaging

• 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.

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.

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.

• Link to Diagnosis Codes

• Link to References