CMM-314: Hip Surgery-Arthroscopic and Open Procedures

Covers arthroscopic or open hip procedures (labral repair/reconstruction, FAI surgery, AVN‑specific procedures, synovectomy, and surgery for fracture/tumor/infection/foreign body) when individually documented as medically necessary, and excludes surgeries outside these indications, cases with exclusionary radiographic features (e.g., Tönnis grade ≥2 or joint‑space narrowing <2 mm), and procedures deemed experimental/investigational (e.g., capsular plication, AIIS/subspinous decompression, in‑office diagnostic arthroscopy). Key requirements include specific clinical findings (e.g., groin‑dominant mechanical pain, positive impingement tests, limited internal rotation as applicable), failure of ≥3 months of provider‑directed non‑surgical management that must include an image‑guided intra‑articular hip injection (with documentation of the response), and confirmatory imaging (MRI/arthrogram and plain radiographs with documented Tönnis grade 0–1 for labral/FAI and procedure‑specific MRI/radiographic criteria for AVN and synovitis); medical necessity is determined case‑by‑case.