CMM-314: Hip Surgery-Arthroscopic and Open Procedures

Arthroscopic or open hip surgery is covered for fractures/malunions, acute/post‑traumatic injuries with exam–imaging correlation, tumor/infection/foreign body/deformity causing progressive destruction, synovial biopsy, irrigation/debridement of infection, removal of radiographically confirmed loose bodies, and for labral repair/reconstruction, femoroacetabular impingement (FAI) procedures and specified avascular necrosis (AVN) procedures when criteria are met; procedures not listed (including capsular plication, AIIS/subspinous decompression, in‑office diagnostic arthroscopy) are considered experimental/investigational and not covered. Coverage requires documented correlation of physical exam and advanced imaging, detailed documentation of provider‑directed non‑surgical treatment (≥3 months) including an image‑guided intraarticular injection that did not relieve symptoms for labral repair/FAI, specific radiographic criteria (e.g., alpha angle >55°, Tönnis 0–1 for FAI), and procedure‑specific imaging/staging limits for AVN.