CMM-314: Hip Surgery-Arthroscopic and Open Procedures

Covers medically necessary arthroscopic or open hip surgeries—including labral repair/reconstruction, FAI surgery, specified AVN procedures, synovectomy, and surgery for acute fracture/tumor/deformity/infection/foreign body—and excludes procedures for other indications, cases with Tönnis grade ≥2 or significant joint space narrowing (<2 mm) and specified EIU procedures (e.g., capsular plication, AIIS/subspinous decompression, in‑office diagnostic arthroscopy). Key requirements: advanced imaging confirming the pathology (and Tönnis 0–1 when applicable), required positive exam findings, failure of ≥3 months of provider‑directed non‑surgical care (and for labral repair/FAI an image‑guided intra‑articular anesthetic injection with documented short‑term pain relief unless contraindicated), plus procedure‑specific imaging criteria for AVN (usually pre‑collapse).

"Labral repair or reconstruction is considered not medically necessary if there is presence of Tönnis grade 2-3 osteoarthritis."