CMM-314: Hip Surgery-Arthroscopic and Open Procedures

Arthroscopic or open hip surgery is covered only for specified indications — acute femoral/acetabular fractures, malunions, tumor/infection/foreign body destruction, synovial biopsy, irrigation/debridement of infection, radiographically confirmed loose body removal, labral pathology, femoroacetabular impingement (FAI), and select AVN procedures — and is considered experimental/unproven for other indications (e.g., capsular plication, anterior inferior iliac spine/subspinous decompression, in‑office diagnostic arthroscopy). Coverage requires documentation of the specific indication with concordant physical exam and advanced imaging meeting procedure‑specific radiographic/stage/lesion‑size criteria (e.g., FAI radiographic signs and Tönnis 0–1; labral tear with mechanical symptoms and positive provocative tests), failure of ≥3 months of provider‑directed non‑surgical care including an image‑guided intraarticular hip injection that did not provide sufficient relief, and case‑by‑case clinical correlation.