Arthroscopic treatment of femoroacetabular impingement (FAI) is considered medically necessary when all of the following conditions have been met:

Age

• Adolescent patients should be skeletally mature with documented closure of growth plates (e.g., 15 years or older). 
• Adult patients should be younger than 55 years of age.

Symptoms

• 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).

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 is considered experimental/investigational in all other situations. A participating, preferred, or network provider can bill the member for the denied service. 

Place of Service: Outpatient

Arthroscopic treatment of FAI is typically an outpatient procedure, which is only eligible for coverage as an inpatient procedure in special circumstances including, but not limited to, the need for therapeutic anticoagulation.

Description

Femoroacetabular impingement (FAI) results from localized compression in the joint due to an anatomical mismatch between the head of the femur and the acetabulum. Symptoms of impingement typically occur in young to middle-aged adults prior to the onset of osteoarthritis, but may be present in younger patients with developmental hip disorders. The objective of surgical treatment of FAI is to improve symptoms and reduce further damage to the joint.

NOTE:

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.

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