29863
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
10.89
Facility
$757.20
Non-Facility
$757.20
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.
- Femoro-acetabular surgery, open or arthroscopic, for the treatment of hip impingement syndrome when ALL of the following criteria are met: Diagnosis of definite femoro-acetabular impingement (FAI) defined by appropriate imaging studies (X-rays, MRI or CT scans), showing labral pathology (e.g. [...]
- Femoro-acetabular surgery, open or arthroscopic, for the treatment of hip impingement syndrome when ALL of the following criteria are met: Moderate to severe symptoms typical of FAI (hip or groin pain that is worsened by flexion activities (e.g., squatting or prolonged sitting) that significantly limits activities, with duration of at least 6 months).
- Femoro-acetabular surgery, open or arthroscopic, for the treatment of hip impingement syndrome when ALL of the following criteria are met: Positive impingement sign with sudden pain on 90 degree hip flexion with adduction and internal rotation or extension and external rotation.
11 Active Policies
CARELON-joint-surgery-2024-11-17-updated-2025-01-01 — Joint Surgery
CARELON-level-of-care-for-surgical-procedures-2025-11-15 — Level of Care for Surgical Procedures
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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