CMM-314: Hip Surgery-Arthroscopic and Open Procedures

Arthroscopic or open hip surgery is considered medically necessary for acute fractures, malunions, post‑traumatic injuries with correlated exam/imaging, tumor/infection/foreign body causing progressive destruction, synovial biopsy, irrigation/debridement for infection, removal of radiographically confirmed loose bodies, labral pathology, femoroacetabular impingement (FAI) with Tönnis grade 0–1, and specified procedures for avascular necrosis (core decompression, osteotomies, curettage/bone grafting, free vascularized fibular graft) per the guideline. Approval requires correlated exam and advanced imaging, documentation of mechanical symptoms and positive provocative hip tests for labral/FAI cases, unresponsiveness to ≥3 months of provider‑directed non‑surgical care including an image‑guided intraarticular injection, and adherence to specific radiographic/AVN thresholds (e.g., alpha angle >55°, Ficat ≤II or <30% femoral head involvement, lesion <15% for varus osteotomy); procedures not listed (e.g., capsular plication, AIIS/subspinous decompression, in‑office diagnostic arthroscopy) are experimental/investigational.