CMM-314: Hip Surgery-Arthroscopic and Open Procedures

EviCore covers arthroscopic or open hip surgery for fracture/tumor/infection/foreign body and for specific indications—labral repair/reconstruction, femoroacetabular impingement (FAI), avascular necrosis (AVN) (specified procedures), and synovectomy—and excludes in‑office diagnostic arthroscopy, capsular plication, anterior inferior iliac spine/subspinous decompression, and any procedures/indications not listed as covered. Coverage requires documented concordant imaging and physical‑exam findings, function‑limiting symptoms, and failure of ≥3 months of provider‑directed non‑surgical care; labral repair and FAI additionally require Tönnis Grade 0–1 and a documented positive response to an image‑guided intra‑articular hip injection, and AVN has procedure‑specific imaging prerequisites.

"Arthroscopic or open hip surgery may be considered medically necessary when surgery is being performed for fracture, tumor, infection, or foreign body that has led to, or will likely lead to, progr..."