|Highmark Commercial Medical Policy - Pennsylvania|
|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)
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:
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.
|Place of Service: Inpatient|
|The policy position applies to all commercial lines of business|
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.