27120
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
18.77
Facility
$1182.73
Non-Facility
$1182.73
Documentation Required
- Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage; refer to the protocol titled Medical Records Documentation Used for Reviews.
- Complete diagnostic interpretation of imaging findings including, at a minimum: relevant clinical information, detailed report of imaging findings, impression, and specialty(ies) of the provider(s) who interpreted the images. (Updated wording in Medical Records Documentation Used for Review.)
- Clinical documentation that would be relevant to applying InterQual® clinical criteria (e.g., symptom description, prior conservative treatment, physical exam findings, patient-reported outcome measures such as WOMAC, HOOS, iHOT-33) may be requested to determine whether criteria for medical necessity are met.
Key Coverage Criteria
- Surgery of the hip and surgical treatment for Femoroacetabular Impingement (FAI) Syndrome is proven and medically necessary in certain circumstances.
- For medical necessity clinical coverage criteria, refer to the InterQual® CP: Procedures: Arthroscopy, Diagnostic, +/- Synovial Biopsy, Hip; Arthroscopy, Surgical, Hip; Arthroscopy, Surgical, Hip (Pediatric); Arthrotomy, Hip; Hemiarthroplasty, Hip; Removal and Replacement, Total Joint Replacement (TJR), Hip; Total Joint Replacement (TJR), Hip.
- Surgical treatment for Femoroacetabular Impingement (FAI) Syndrome (including procedures such as arthroscopy with femoroplasty (29914), acetabuloplasty (29915), labral repair (29916), and related hip arthroscopy/arthroplasty procedures) when clinical criteria for medical necessity are met as defined by the referenced InterQual® criteria.
4 Active Policies
CARELON-joint-surgery-2024-11-17-updated-2025-01-01 — Joint Surgery
UHC-POL-surgery-hip — Surgery of the Hip
UMR-POL-UMR-surgery-hip — Surgery of the Hip
SUREST-POL-SUREST-surgery-hip — Surgery of the Hip
Related Codes
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