CMM-314: Hip Surgery-Arthroscopic and Open Procedures

This guideline authorizes arthroscopic or open hip surgery only for specified indications (acute fracture/malunion, tumor/infection/foreign body with progressive destruction, synovial biopsy/irrigation‑debridement, radiographically‑confirmed loose body removal, labral repair/reconstruction meeting criteria, FAI meeting imaging/Tönnis criteria, specified AVN procedures with stage/lesion‑size limits, and other listed pelvic/hip procedures) and states procedures not listed or explicitly named (e.g., capsular plication, anterior inferior iliac spine/subspinous decompression, in‑office diagnostic arthroscopy) are experimental/unproven. Key requirements are documented correlation of physical exam and advanced imaging (including specific measurements/Tönnis grade), radiographic confirmation where applicable, and for labral repair and FAI ≥3 months of provider‑directed non‑surgical care including an image‑guided intra‑articular injection without a favorable response; AVN procedures require procedure‑specific imaging stage/lesion‑size criteria (e.g., Ficat/Arlet ≤II or <30% head involvement for core decompression, <15% lesion for varus osteotomy).