CMM-314: Hip Surgery-Arthroscopic and Open Procedures

Policy covers arthroscopic and open hip surgery as medically necessary for acute fractures/malunions, acute/post‑traumatic injuries with exam–imaging correlation, persistent non‑traumatic hip pain ≥3 months (e.g., AVN, loose bodies, dysplasia), tumor/infection, and FAI; arthroscopy is also allowed for FAI meeting strict criteria, labral pathology with mechanical symptoms and advanced imaging confirmation, synovial biopsy, irrigation/debridement for joint infection, and removal of radiographically confirmed loose bodies, while all other arthroscopic indications and procedures (including capsular plication and AIIS/sub‑spinous decompression) are experimental/investigational. Key requirements: for FAI (arthroscopic or open) must have a positive impingement sign, moderate–severe flexion‑worse pain limiting activity, ≥3 months of physician‑directed non‑operative care, radiographic confirmation of FAI (e.g., pistol‑grip/alpha angle >50°), documented proximal femoral physis closure and absence of Tönnis grade 2–3 or joint space <2 mm; exam–imaging correlation is required for acute/post‑traumatic cases, labral surgery needs advanced imaging confirmation, and loose body removal requires radiographic proof.