Description
General Information
It is an expectation that all patients receive care/services from a licensed clinician. All appropriate supporting documentation, including recent pertinent office visit notes, laboratory data, and results of any special testing must be provided. If applicable: All prior relevant imaging results and the reason that alternative imaging cannot be performed must be included in the documentation submitted.

Purpose
This guideline addresses the following elective, non-emergent, arthroscopic hip repair procedures, including, diagnostic arthroscopy, femoroacetabular impingement (FAI), labral repair only; CAM, pincer, CAM & pincer combined; synovectomy, biopsy, or removal of loose or foreign body.

Scope
Open, non-arthroplasty hip repair surgeries are performed as dictated by the type and severity of injury and/or disease.

Surgical indications are based on relevant clinical symptoms, physical exam, radiologic findings, and response to non-operative, conservative management when medically appropriate.

GENERAL REQUIREMENTS

• Elective arthroscopic surgery of the hip may be considered if the following general criteria are met:
  • There is clinical correlation of the individual’s subjective complaints with objective exam findings and/or imaging (when applicable)
  • Individual has limited function (age-appropriate activities of daily living [ADLs], occupational, athletic)
  • Individual is medically stable and optimized for surgery and any treatable comorbidities are adequately medically managed such as diabetes, nicotine addiction, or an excessively high BMI. There should also be a shared decision between the patient and physician to proceed with arthroscopic hip surgery when comorbidities exist as it pertains to the increased risk of complications.
  • Individual does not have an active local or systemic infection
  • Individual does not have active, untreated drug dependency (including but not limited to narcotics, opioids, muscle relaxants) unless engaged in treatment program
• Clinical notes should address:
  • Symptom onset, duration, and severity
  • Loss of function and/or limitations
  • Type and duration of non-operative management modalities (where applicable)
• Non-operative management must include TWO or more of the following, unless otherwise specified:
  • Physical therapy or properly instructed home exercise program
  • Rest or activity modification
  • Ice/Heat
  • Protected weight bearing
  • Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, analgesics
  • Brace/orthosis
  • Weight optimization
  • Corticosteroid injections

Policy
INDICATIONS
Diagnostic or operative arthroscopy of the hip is considered MEDICALLY NECESSARY when performed in conjunction with periacetabular osteotomy (PAO)^(1,2,3) OR as indicated in the following sections:

Diagnostic Hip Arthroscopy
All requests for diagnostic hip arthroscopy will be considered and decided on a case-by-case basis and are rarely deemed MEDICALLY NECESSARY.

However, on occasion, diagnostic hip arthroscopy is considered MEDICALLY NECESSARY when ALL of the following criteria are met:

• At least 6 months of hip pain with documented loss of function
• Indeterminate radiographs AND MRI findings
• No radiographic findings of any of the following:
  • Significant arthritis (joint space less than 2 mm on X-ray or subchondral edema on MRI)⁽³⁾
  • Femoroacetabular impingement (non-spherical femoral head or prominent head-neck junction (pistol-grip deformity), alpha angle > 50 degrees, overhang of the anterolateral rim of the acetabulum, posterior wall sign, prominent ischial spine sign, acetabular protrusion, or retroversion with a center edge (CE) angle > 35° and/or cross-over sign)⁽⁴⁾
  • Hip dysplasia (lateral center edge angle < 20 degrees, anterior center edge angle < 20 degrees, Tönnis angle > 15 degrees or femoral head extrusion index > 25%), unless combined with concomitant periacetabular osteotomy^(1,3)
  • Fractures of the femoral head or acetabulum
  • Labral tear (on MRI or MR arthrogram)
  • Pigmented villonodular synovitis (PVNS) or synovial chondromatosis
  • Intra-articular loose body
  • Adductor tear or hamstring tear
  • Pubic edema or osteitis pubis
  • Gluteus medius or minimus tear
  • Ischiofemoral impingement (narrowed ischiofemoral and quadratus femoris spaces)
• Failure of at least 12 weeks of non-operative treatment, including at least two of the following:
  • Rest or activity modifications/limitations
  • Ice/heat
  • Protected weight bearing
  • Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, analgesics, tramadol
  • Brace/orthosis
  • Physical therapy or properly instructed home exercise program
  • Weight optimization
  • Corticosteroid injection
• No cortisone injection within 3 months of surgery^(5,6)

Labral Tears and Femoroacetabular Impingement (FAI)
Labral Repair
Arthroscopic labral repair is considered MEDICALLY NECESSARY when ALL of the following criteria are met^(3,4,7):

• Hip or groin pain in positions of flexion and rotation that may be associated with mechanical symptoms of locking, popping, or catching
• Positive provocative test on physical exam with pain at the hip joint with flexion, adduction, and internal rotation (FADIR test)
• Acetabular labral tear on MRI, with or without intra-articular contrast
• No evidence of significant hip joint arthritis, defined as joint space narrowing 2 mm or less or Tönnis grade 3 or evidence of severe or advanced dysplasia [see Grading Appendix] unless combined with concomitant periacetabular osteotomy^(3,4,7)
• Weight-bearing X-rays are not required
• Failure of at least 6 weeks of non-operative treatment, including at least two of the following:
  • Physical therapy or properly instructed home exercise program
  • Rest or activity modification
  • Ice/heat
  • Protected weight bearing
  • Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, analgesics
  • Weight optimization
  • Corticosteroid injection
• No cortisone injection within 3 months of surgery^(5,6)

CAM, Pincer, Combined CAM & Pincer Repair
Arthroscopic CAM, pincer or combined CAM and pincer repair is considered MEDICALLY NECESSARY when ALL of the following criteria are met ^(3,4,7,8):

• Positional hip pain
• Skeletally mature patient [partial or complete closure of the proximal femoral physis]
• BMI < 40 ⁽⁹⁾; Individuals with BMI > 40 will be reviewed on a case-by-case basis
• Positive impingement sign on physical exam (hip or groin pain with flexion, adduction, and internal rotation (FADIR test) ⁽¹⁰⁾
• ANY of the following radiograph, CT and/or MRI findings of FAI:
  • Non-spherical femoral head or prominent head-neck junction (pistol-grip deformity) with alpha angle > 50 degrees indicating CAM impingement [see radiographic measurement appendix]
  • Overhang of the anterolateral rim of the acetabulum, posterior wall sign, prominent ischial spine sign, acetabular protrusion, or retroversion with a center edge (CE) angle > 35° and/or cross-over sign indicating pincer deformity [see radiographic measurement appendix]
  • Combination of CAM and pincer criteria
• No evidence of significant hip joint arthritis, defined as joint space narrowing 2 mm or less or a Tönnis Grade 3 or evidence of severe or advanced hip dysplasia [see Grading Appendix] unless combined with concomitant periacetabular osteotomy (See Background Additional Notes) ⁽¹¹⁾
• Radiographic images show no evidence of severe or advanced hip dysplasia [see Grading Appendix] unless combined with concomitant periacetabular osteotomy**
• Failure of at least 6 weeks of non-operative treatment, including at least two of the following ⁽¹²⁾:
  • Physical therapy or properly instructed home exercise program
  • Rest or activity modification
  • Ice/heat
  • Protected weight bearing
  • Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, analgesics
  • Weight optimization
  • Corticosteroid injection
• No cortisone injection within 3 months of surgery ^(5,6)

Arthroscopy for Synovectomy, Biopsy, or Removal of Loose or Foreign Body
Arthroscopic synovectomy, biopsy, removal of loose or foreign body, or a combination of these procedures may be medically necessary when the following criteria in either section are met ⁽³⁾:

Section One

• X-ray, MRI, or CT evidence of acute post-traumatic intra-articular foreign body or displaced fracture fragment

Section Two

• When ALL of the following criteria are met:
  • Hip pain associated with grinding, catching, locking, or popping
  • Physical examination demonstrates painful range of motion of the hip
  • Radiographs, CT, and/or MRI demonstrate synovial proliferation, calcifications, nodularity, inflammation, pannus, or a loose body
  • Failure of at least 12 weeks of non-operative treatment, including at least two of the following:
    • Physical therapy or properly instructed home exercise program
    • Rest or activity modification
    • Ice/heat
    • Protected weight bearing
    • Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, analgesics
    • Weight optimization
    • Corticosteroid injection
• No cortisone within 3 months of surgery ^(5,6)

Rationale
There is no evidence to support hip arthroscopy for FAI and/or labral tear in an asymptomatic individual and there is a high prevalence of abnormal radiographs found in asymptomatic individuals ⁽¹⁴⁾: 33% of asymptomatic hips have a cam lesion, 66% of asymptomatic hips have a pincer lesion, and 68% of asymptomatic hips have a labral tear. ^(2,4)

*Even though hip dysplasia, as well as symptomatic FAI and labral tears are believed to be precursors to hip arthritis, arthroscopy is not indicated solely for the treatment of osteoarthritis of the hip and rarely indicated for severe dysplasia, unless combined with concomitant periacetabular osteotomy. However, individuals with borderline dysplasia (lateral center-edge angle [LCEA], 18° to 25°), that require arthroscopic procedures appear to do as well as those with no evidence of dysplasia. ^(1,4,7)

Recent literature has demonstrated that individuals who undergo hip arthroscopy for femoroacetabular impingement syndrome and have an unrepaired capsule have lower functional outcome scores, achievement of meaningful outcomes, success rates, as well as greater failure rates and reported pain when compared with individuals who have complete capsular closure. ^(15,16)

Grading Appendix
Tonnis Classification of Osteoarthritis by Radiographic Changes

Hip Dysplasia
Defined as any of the following criteria ^(1,4,7):

• Lateral center edge angle < 20 degrees
• Anterior center edge angle < 20 degrees
• Tönnis angle > 15 degrees
• Femoral head extrusion index > 25%
• Borderline dysplasia (lateral center-edge angle [LCEA], 18° to 25°)

Radiographic Measurement Index⁽¹⁸⁾
Alpha Angle

• Alpha angle was measured on the AP pelvis and Dunn 45° radiographs. First, a Mose circle was placed around the circumference of the femoral head. A line was drawn from the center of the femoral head down the center of the femoral neck. A line was then drawn connecting the center of the femoral head to the point of the Mose circle where the head goes out of round. The angle bisecting these two lines was the alpha angle
  • An alpha angle of 55° (Dunn 45°) or greater or an alpha angle of 50° (AP pelvis) was defined as cam morphology

Femoral Head Intrusion

• Femoral head extrusion index was measured as the proportion (%) of laterally uncovered femoral head versus the femoral head (horizontal distance)
  • A femoral head extrusion index greater than 25% defined dysplasia

Global Acetabular Retroversion

• Global acetabular retroversion was defined by the presence of a prominent ischial spine sign or posterior wall sign
  • Prominent ischial spine sign: Visible ischial spine medial to the iliopectineal line on AP pelvis radiograph
  • Posterior wall sign: Center of the femoral head lateral to the posterior wall of the acetabulum

Lateral Center Edge Angle

• Lateral center edge angle was measured after multiple lines were drawn on the AP pelvis radiograph. First, a Moses circle was placed around the circumference of the femoral head. Next, a line was drawn connecting the ischial tuberosities. A perpendicular line was then drawn up through the center of the femoral head from the ischial tuberosity line. Then, a line was drawn from the center of the femoral head to the most lateral aspect of the sourcil. The angle bisecting the latter two lines was the lateral center edge angle
  • A lateral center edge angle less than 20° defines dysplasia, 20 to 25° borderline dysplasia, 26 to 39° normal, and greater than 40° lateral over coverage pincer impingement
  • Lateral over coverage was defined as a lateral center edge angle greater than 40° 

References

1. Barton C, Scott E, Khazi Z, Willey M, Westermann R. Outcomes of Surgical Management of Borderline Hip Dysplasia: A Systematic Review. The Iowa orthopaedic journal. 2019; 39: 40-48. 
2. Jamil M, Dandachli W, Noordin S, Witt J. Hip arthroscopy: Indications, outcomes and complications. International Journal of Surgery. 2018; 54: 341-344. 10.1016/j.ijsu.2017.08.557. 
3. Ross J, Larson C, Bedi A. Indications for Hip Arthroscopy. Sports Health. 2017; 9: 402-413. 10.1177/1941738117712675. 
4. O'Rourke R J, El Bitar Y. Femoroacetabular Impingement. StatPearls Publishing. 2023 (June 26); Accessed: September 13, 2024. https://www.ncbi.nlm.nih.gov/books/NBK547699/. 
5. Aamer S, Tokhi I, Asim M, Akhtar M, Razick D et al. Postoperative Infection Following Hip Arthroscopy in Patients Receiving Preoperative Intra-articular Injections: A Systematic Review and Meta-Analysis. Cureus. 2024; 10.7759/cureus.61649. 
6. Wang D, Camp C, Ranawat A, Coleman S, Kelly B. The Timing of Hip Arthroscopy After Intra-articular Hip Injection Affects Postoperative Infection Risk. Arthroscopy - Journal of Arthroscopic and Related Surgery. 2017; 33: 1988-1994.e1. 10.1016/j.arthro.2017.06.037. 
7. Mella C, Villalón I, Núñez Á, Paccot D, DÍaz-Ledezma C. Hip arthroscopy and osteoarthritis: Where are the limits and indications? SICOT-J. 2015; 1: 10.1051/sicotj/2015027. 
8. Lynch T, Minkara A, Aoki S, Bedi A, Bharam S et al. Best Practice Guidelines for Hip Arthroscopy in Femoroacetabular Impingement: Results of a Delphi Process. Journal of the American Academy of Orthopaedic Surgeons. 2020; 28: 81-89. 10.5435/JAAOS-D-18-00041. 
9. Parvaresh K, Rasio J, Wichman D, Chahla J, Nho S. The Influence of Body Mass Index on Outcomes After Hip Arthroscopy for Femoroacetabular Impingement Syndrome: Five-Year Results in 140 Patients. American Journal of Sports Medicine. 2021; 49: 90-96. 10.1177/0363546520976357. 
10. Pålsson A, Kostogiannis I, Ageberg E. Combining results from hip impingement and range of motion tests can increase diagnostic accuracy in patients with FAI syndrome. Knee Surgery, Sports Traumatology, Arthroscopy. 2020; 28: 3382-3392. 10.1007/s00167-020-06005-5. 
11. Lei P, Conaway W, Martin S. Outcome of Surgical Treatment of Hip Femoroacetabular Impingement Patients with Radiographic Osteoarthritis: A Meta-analysis of Prospective Studies. Journal of the American Academy of Orthopaedic Surgeons. 2019; 27: E70-E76. 10.5435/JAAOS-D-17-00380. 
12. Casartelli N, Bizzini M, Maffiuletti N, Sutter R, Pfirrmann C et al. Exercise Therapy for the Management of Femoroacetabular Impingement Syndrome: Preliminary Results of Clinical Responsiveness. Arthritis Care & Research. 2019; 71: 1074-1083. 10.1002/acr.23728. 
13. Washington State Health Care Authority. Health Technology Assessment: Femoroacetabular Impingement Syndrome. Online. 2020; 
14. Lee A, Armour P, Thind D, Coates M, Kang A. The prevalence of acetabular labral tears and associated pathology in a young asymptomatic population. The Bone Joint Journal. 2015; 97-B: 623-627. 10.1302/0301-620X.97B5.35166. 
15. Arakgi M, Degen R. Approach to a Failed Hip Arthroscopy. Current Reviews in Musculoskeletal Medicine. 2020; 13: 233-239. 10.1007/s12178-020-09629-9. 
16. Bolia I, Briggs K, Philippon M. Superior Clinical Outcomes with Capsular Closure versus Non-Closure in Patients Undergoing Arthroscopic Hip Labral Repair. Orthopaedic Journal of Sports Medicine. 2018; 6: 2325967118S0000. 10.1177/2325967118s00009. 
17. Kovalenko B, Bremjit P, Fernando N. Classifications in brief: Tönnis classification of hip osteoarthritis. Clinical Orthopaedics and Related Research. 2018; 476: 1680-1684. 10.1097/01.blo.0000534679.75870.5f. 
18. Mannava S, Geeslin A, Frangiamore S, Cinque M, Geeslin M et al. Comprehensive Clinical Evaluation of Femoroacetabular Impingement: Part 2, Plain Radiography. Arthroscopy Techniques. 2017; 6: e2003-e2009. 10.1016/j.eats.2017.06.011.

Coding Section

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

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