Arthroscopic treatment of the following conditions is considered medically necessary when all of the following conditions have been met.

For femoroacetabular impingement (FAI)
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. 

For labral tears of the hip
Arthroscopic treatment of labral tears of the hip is 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 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 and/or labral teards of the hip 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.

The etiology of labral tears of the hip includes trauma, femoroacetabular impingement (FAI), capsular laxity/hip hypermobility, dysplasia, and degeneration. Labral tears present with anterior hip or groin pain, and less commonly buttock pain. Treatment typically begins conservatively, but often, surgical treatment is necessary, which entails, arthroscopic debridement of labral tears and surgical repair of associated structural problems.

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.

This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits, or a contract. Benefits are determined by the Federal Employee Program.

Byrd JW, Jones KS. Hip arthroscopy for labral pathology: Prospective analysis with a 10-year follow-up. Arthrscopy: The Journal of Arthroscopic and Related Surgery. 2009;25(4):365-368.

Kamath AF, Componovo R, Baldwin K, Israelite CL, Nelson CL. Hip arthroscopy for labral tears. Review of clinical outcomes with a 4.8 year mean follow-up. Am J Sports Med. 2009;37(9):1721-1727.

Groh MM, Herrera J. A comprehensive review of hip labral tears. Curr Rev Musculoskeletal Med. 2009;2(2):105-117.

Larson CM, Guanche CA, Kelly BT, CLohisy JC, Ranawat AS. Advanced techniques in hip arthroscopy. Instr Course Lect. 2009;58:423-436.

Beaulé PE, O’Neill M, Rakhra K. Acetabular Labral Tears. J Bone Joint Surg Am. 2009;91:701-710.

Blue Cross Blue Shield Association. Medical Policy Reference Manual 7.01.118. Surgical Treatment of Femoroacetabular Impingement. Issued May 2010.

Clohisy JC, Zebala LP, Nepple JJ, Pashos G. Combined hip arthroscopy and limited open osteochondroplasty for anterior femoroacetabular impingement. J Bone Joint Surg Am. 2010;92(8):1697-1706.

Gédouin JE, Dupperon D, Langlais F, Thomazeau H. Update to femoroacetabular impingement arthroscopic management. Orthop Traumatol Surg Res. 2010;96(3):222-227.

Gédouin JE, Bonin N, Nogier A, et al.  Assessment of arthroscopic management of femoroacetabular impingement. A prospective multicenter study. Orthop Traumatol Surg Res. 2010;96(8 Suppl):S59-67.

Haviv B, O’Donnell J. Arthroscopic treatment for symptomatic bilateral cam-type femoroacetabular impingement. Orthopedics. 2010;33(12):874.

Zlatkin MB, Pevsnar D, Sanders TG, et al. Acetabular labral tears and cartilage lesions of the hip: Indirect MR Arthrographic correlation with arthroscopy – A preliminary study. American Journal of Roentgenology. 2010;194:709-714.

Stevens MS. The evidence for hip arthroscopy: grading the current indications. Arthroscopy. 2010;26(10):1370-1383.

Nord RM, Meislin RJ. Hip arthroscopy in adults. Bull NYU Hosp Jt Dis. 2010;68(2):97-102.

Vilchez F. Learning curve of arthroscopic hip surgery. Acta Ortop Mex. 2010;24(3):177-181.

Macfarlane RJ. The diagnosis and management of femoro-acetabular impingement. Ann R Coll Surg Engl. 2010;92(5):363-367.

Armand MM. Hip arthroscopy: Treating femoroacetabular impingement. The Surgical Technologist. 2010:219-226.

Rush University Medical Center. New study finds arthroscopic hip surgery may fully restore function in athletes. 2010. Available at: www.esciencenews.com/articles/2010/07/19/new.study.finds.arthroscopic.hip.surgery. Accessed February 22, 2011.

Eneski KR, Martin RR, Kelly BT. Rehabilitation after arthroscopic decompression for femoroacetabular impingement. Clin Sports Med. 2010;29:247-255.

Dienst M, Kusma M, Steimer O, Holzhoffer P, Kohn D. Arthroscopic resection of the cam deformity of femoroacetabular impingement. Oper Orthop Traumatol. 2010;22(1):29-43.

Nho SJ, Magennis E, Singh C, KellyB. Paper 28: Outcomes after the arthroscopic treatment of femoroacetabular impingement in a mixed group of high level athletes. Arthroscopy: The Journal of Arthroscopic and Related Surgery. 2011;27(1):e16-e17.

Botser IB, Smith TW, Domb B. Paper 17: Open surgical dislocation versus arthroscopic treatment of femoroacetabular impingement: A prospective comparison of a single surgeon clinical results. Arthroscopy: The Journal of Arthroscopic and Related Surgery. 2011;27(1):e-10.

Botser IB, Smith TW Jr, Nasser R, Domb BG. Open surgical dislocation versus arthroscopy for femoroacetabular impingement: a comparison of clinical outcomes. Arthroscopy. 2011;27(2):270-278.

Matsuda DK, Carlisle JC, Arthurs SC, Wierks CH, Philippon MJ. Comparative systematic review of the open dislocation, mini-open, and arthroscopic surgeries for femoroacetabular impingement. Arthroscopy: The Journal of Arthroscopic and Related Surgery. 2011;27(2):252-269.

O’Donnell JM, Singh PJ, Pritchard MG. Paper 30: The outcome of hip arthroscopy in teenagers-A review of 96 cases. Arthroscopy: The Journal of Arthroscopic and Related Surgery. 2011;27(1):e17-e18.

Ejnisman L, Philippon MJ, Briggs KK, Lertwanich P. Paper 14: Outcomes following hip arthroscopy for FAI in the adolescent patient. Arthroscopy: The Journal of Arthroscopic and Related Surgery. 2011;27(1):e9.

Nabavi-Tabrizi A. Paper 33: Short to medium term results of arthroscopic hip surgery for the treatment of femoroacetabular impingement. Arthroscopy: The Journal of Arthroscopic and Related Surgery. 2011;27(1):e19.

American College of Rheumatology. Practice Guidelines: Recommendations for the medical management of osteoarthritis of the hip and knee. Submitted for publication January 29, 2000, accepted in revised form May 12, 2000. Available at: www.rheumatology.org/practice/clinical/guidelines/oa-mgmt.asp. Accessed March 4, 2011.

Kocher MS, Solomon R, Lee BM, Michell LJ, Solomon J, Stubbs A. Article: Arthroscopic debridement of hip labral tears in dancers. Journal of Dance and Medicine & Science. 2006. Available at: www.highbeam.com/doc/1G1-165576516.html. Accessed March 9, 2011.

Cluett J. Labral Tear of the hip joint. 2009. Available at: www.orthopedics.about.com/od/hipinjuries/qt/labrum.htm. Accessed March 9, 2011.

Streich NA, Gotterbarm T, Jung M, Schmitt H. Outcome of arthroscopic resection of labral tears. Z Orthop Unfall. 2007;145(5):633-638.

Parvizi J, Bican O, Bender B, et al. Arthroscopy for labral tears in patients with developmental dysplasia of the hip: A cautionary note. J Arthroplasty. 2009;24(Suppl):110-113.

Lee HH, Klika AK, Bershadsky B, Krebs VE, Barsoum WK. Factors affecting recovery after arthroscopic labral debridement of the hip. Arthroscopy. 2010;26(3):328-334.

Haviv B, O’Donnell J. Arthroscopic treatment for acetabular labral tears of the hip without bony dysmorphism. Am J Sports. 2011;39 Suppl:79S-84S.

Matsuda DK, Carlisle JC, Arthurs SC, Wierks CH, Philippon MJ. Comparative systematic review of the open dislocation, mini-open, and arthroscopic surgeries for femoroacetabular impingement. Arthroscopy: The Journal of Arthroscopic and Related Surgery. 2011;27(2):252-269.

Javed A, O’Donnell JM. Paper 35: Arthroscopic femoral osteochondroplasty for cam femoroacetabular impingement in patients over 60 years of age. Arthroscopy: The Journal of Arthroscopic and Related Surgery. 2011;27(1):e20.