Femoroacetabular Impingement (FAI) is a condition that has been recently recognized, is an anatomical mismatch between the head of the femur and the acetabulum resulting in compression of the labrum or articular cartilage during flexion. The mismatch can arise from subtle morphologic alterations in the anatomy or orientation of the ball-and-socket components (for example, a bony prominence at the head-neck junction or acetabular over coverage) with articular cartilage damage initially occurring from abutment of the femoral neck against the acetabular rim, typically at the anterosuperior aspect of the acetabulum. Although hip joints can possess the morphologic features of FAI without symptoms, FAI may become pathologic with repetitive movement and/or increased force on the hip joint. High- demand activities may also result in pathologic impingement in hips with normal morphology.

Two types of impingement, known as CAM impingement and pincer impingement may occur alone or more frequently together.

CAM impingement is associated with an asymmetric or non-spherical contour of the head or neck of the femur jamming against the acetabulum, resulting in cartilage damage and delamination (detachment from the subchondral bone). Deformity of the head/neck junction that looks like a pistol grip on radiographs is associated with damage to the anterosuperior area of the acetabulum. Symptomatic CAM impingement is found most frequently in young male athletes.

Pincer impingement is associated with over-coverage of the acetabulum and pinching of the labrum, with pain more typically beginning in women of middle age. In cases of isolated pincer impingement, the damage may be limited to a narrow strip of the acetabular cartilage. It has been proposed that impingement with damage to the labrum and/or acetabulum is a causative factor in the development of hip osteoarthritis, and that as many as half of cases currently categorized as primary osteoarthritis may have an etiology of FAI.

Non-arthroscopic hip surgery, may be considered medically necessary for ANY of the following clinical situations:

·         Individual has experienced an acute fracture of the hip (femoral or acetabular); or

·         Individual has a mal-union of a previous fracture; or

·         Individual has experienced an acute or post traumatic injury in which there is a correlation between examination and diagnostic imaging findings confirming a condition which is reasonably suspected of producing the individual’s severe pain and limitation in function; or

·         Individual with persistent hip pain or dysfunction of a non-traumatic etiology for at least three (3) months in duration (e.g., avascular necrosis, loose bodies, dysplasia); or

·         Tumor or infection; or

·         Femoroacetabular Impingement (FAI) Syndrome, including labral tear or synovial biopsy when an individual has ALL of the following criteria:

o    Positive impingement sign (i.e., sudden pain on 90 degree hip flexion with adduction and internal rotation or extension and external rotation); and

o    Moderate to severe hip pain that is worsened by flexion activities (e.g. squatting or prolonged sitting) that significantly limits activities; and

o    Unresponsive to at least three (3) months of physician-directed non-surgical care; and

o    Radiographic confirmation of FAI (e.g., pistol-grip deformity, alpha angle greater than 50 degrees, coxa profunda, and/or acetabular retroversion); and

o    Documented closure of the proximal femoral physis; and

o    Documented absence of ALL of the following:

§  Tönnis grade two (2) osteoarthritis (i.e., small cysts in femoral head or acetabulum, increasing narrowing of joint space, moderate loss of sphericity of femoral head); and

§  Tönnis grade three (3) osteoarthritis (i.e., large cysts, severe narrowing or obliteration of joint space, severe deformity of femoral head, avascular necrosis; and

§  Joint space is less than two (2) mm wide anywhere along the sourcil.

Arthroscopic hip surgery may be considered medical necessary for ANY of the following clinical situations:

·         Femoroacetabular Impingement (FAI) Syndrome when an individual has ALL of the following criteria:

o    Positive impingement sign (i.e., sudden pain on 90 degree hip flexion with adduction and internal rotation or extension and external rotation); and

o    Moderate to severe hip pain that is worsened by flexion activities (e.g. squatting or prolonged sitting) that significantly limits activities; and

o    Unresponsive to at least 3 months of physician-directed non-surgical care; and

o    Radiographic confirmation of FAI (e.g., pistol-grip deformity, alpha angle greater than 50 degrees, coxa profunda, and/or acetabular retroversion); and

o    Documented closure of the proximal femoral physis; and

o    Documented absence of ALL of the following:

§  Tönnis grade two (2) osteoarthritis (i.e., small cysts in femoral head or acetabulum, increasing narrowing of joint space, moderate loss of sphericity of femoral head); and

§  Tönnis grade three (3) osteoarthritis (i.e., large cysts, severe narrowing or obliteration of joint space, severe deformity of femoral head, avascular necrosis; and

§  Joint space is less than two (2) mm wide anywhere along the sourcil.

·         In conjunction with a periacetabular osteotomy; or

·         Labral pathology when an individual has ALL of the following criteria:

o    Mechanical symptoms of the hip catching, locking or giving way; and

o    An advanced diagnostic imaging study confirming labral pathology amenable to surgical management; or

·         Synovial biopsy; or

·         Irrigation and debridement of an intra-articular joint space infection; or

·         Removal of an ossific or osteochondral loose body confirmed radiographically; or

Arthroscopic hip surgery is considered experimental/investigational for all other indications.

The performance of capsular plication and anterior inferior iliac spine/sub-spinous decompression is considered experimental/investigational and therefore non-covered as the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.