This Medical Policy is provided for informational purposes only.

If Members have any questions about the medical necessity of a service or procedure, they should discuss the question with their Network Provider or call a member of our Customer Service Team.

MEDICAL POLICY USE DISCLAIMER

  1. Medical Policy is used by Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company ("BCBSMS") as one set of guidelines (among other sets of guidelines) to assist BCBSMS in making benefit coverage decisions. BCBSMS utilizes Medical Policy adopted by our Medical Policy Advisory Committee ("MPAC") which is supported by the Blue Cross and Blue Shield Association Medical Policy, research and development. Medical Policies are the property of BCBSMS and any use of Medical Policy not agreed to by BCBSMS is strictly prohibited. The use of Medical Policy for purposes related to the health care of a BCBSMS plan member is permitted and is not a violation of the proprietary rights of BCBSMS.
  2. These Medical Policies are based on scientifically meritorious evidence provided through research for a particular medical technology. Medical Policy is also based on data from peer-reviewed scientific literature, from criteria developed by specialty societies and from guidelines adopted by other health care organizations.
  3. These Medical Policies apply to members/subscribers who have health insurance through BCBSMS. This Medical Policy also applies to Members of a self-insured group health plan for which Blue Cross & Blue Shield of Mississippi provides claims administration and persons covered by a Medicare Supplement policy offered by BCBSMS. This Medical Policy does not apply to any other individuals. Medical Policies may differ for Federal employees covered under the Federal Employees Health Benefits Plan.
  4. In the event of any conflict between this Medical Policy and any benefit plan, Summary Plan Description or other coverage document, the benefit plan, Summary Plan Description or other coverage document will govern.
  5. Medical technology is rapidly changing and these Medical Policies are subject to change without notice. Also, please be aware that as a result of ongoing changes being made to Medical Policy, BCBSMS cannot and does not guarantee that these Medical Policies are current.

BCBSMS Medical Policies are Subject to the Following Restrictions


This Medical Policy is provided for informational purposes only.

If Members have any questions about the medical necessity of a service or procedure, they should discuss the question with their Network Provider or call a member of our Customer Service Team.

MEDICAL POLICY USE DISCLAIMER

  1. Medical Policy is used by Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company ("BCBSMS") as one set of guidelines (among other sets of guidelines) to assist BCBSMS in making benefit coverage decisions. BCBSMS utilizes Medical Policy adopted by our Medical Policy Advisory Committee ("MPAC") which is supported by the Blue Cross and Blue Shield Association Medical Policy, research and development. Medical Policies are the property of BCBSMS and any use of Medical Policy not agreed to by BCBSMS is strictly prohibited. The use of Medical Policy for purposes related to the health care of a BCBSMS plan member is permitted and is not a violation of the proprietary rights of BCBSMS.
  2. These Medical Policies are based on scientifically meritorious evidence provided through research for a particular medical technology. Medical Policy is also based on data from peer-reviewed scientific literature, from criteria developed by specialty societies and from guidelines adopted by other health care organizations.
  3. These Medical Policies apply to members/subscribers who have health insurance through BCBSMS. This Medical Policy also applies to persons covered by the Mississippi Children's Health Insurance Program, Members of a self-insured group health plan for which Blue Cross & Blue Shield of Mississippi provides claims administration and persons covered by a Medicare Supplement policy offered by BCBSMS. This Medical Policy does not apply to any other individuals. Medical Policies may differ for Federal employees covered under the Federal Employees Health Benefits Plan.
  4. In the event of any conflict between this Medical Policy and any benefit plan, Summary Plan Description or other coverage document, the benefit plan, Summary Plan Description or other coverage document will govern.
  5. Medical technology is rapidly changing and these Medical Policies are subject to change without notice. Also, please be aware that as a result of ongoing changes being made to Medical Policy, BCBSMS cannot and does not guarantee that these Medical Policies are current.

BCBSMS Medical Policies are Subject to the Following Restrictions


This Medical Policy is provided for informational purposes only.

If Members have any questions about the medical necessity of a service or procedure, they should discuss the question with their Network Provider or call a member of our Customer Service Team.

MEDICAL POLICY USE DISCLAIMER

  1. Medical Policy is used by Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company ("BCBSMS") as one set of guidelines (among other sets of guidelines) to assist BCBSMS in making benefit coverage decisions. BCBSMS utilizes Medical Policy adopted by our Medical Policy Advisory Committee ("MPAC") which is supported by the Blue Cross and Blue Shield Association Medical Policy, research and development. Medical Policies are the property of BCBSMS and any use of Medical Policy not agreed to by BCBSMS is strictly prohibited. The use of Medical Policy for purposes related to the health care of a BCBSMS plan member is permitted and is not a violation of the proprietary rights of BCBSMS.
  2. These Medical Policies are based on scientifically meritorious evidence provided through research for a particular medical technology. Medical Policy is also based on data from peer-reviewed scientific literature, from criteria developed by specialty societies and from guidelines adopted by other health care organizations.
  3. These Medical Policies apply to members/subscribers who have health insurance through BCBSMS. This Medical Policy also applies to persons covered by the Mississippi Children's Health Insurance Program, Members of a self-insured group health plan for which Blue Cross & Blue Shield of Mississippi provides claims administration and persons covered by a Medicare Supplement policy offered by BCBSMS. This Medical Policy does not apply to any other individuals. Medical Policies may differ for Federal employees covered under the Federal Employees Health Benefits Plan.
  4. In the event of any conflict between this Medical Policy and any benefit plan, Summary Plan Description or other coverage document, the benefit plan, Summary Plan Description or other coverage document will govern.
  5. Medical technology is rapidly changing and these Medical Policies are subject to change without notice. Also, please be aware that as a result of ongoing changes being made to Medical Policy, BCBSMS cannot and does not guarantee that these Medical Policies are current.

BCBSMS Medical Policies are Subject to the Following Restrictions

Medical Policy Search
Printer Friendly Version Surgical Treatment of Femoroacetabular Impingement

Surgical Treatment of Femoroacetabular Impingement

 

DESCRIPTION

 Femoroacetabular impingement (FAI) results from localized compression in the joint due to an anatomical mismatch between the head of the femur and the acetabulum. Symptoms of impingement typically occur in young to middle-aged adults prior to the onset of osteoarthritis, but may be present in younger patients with developmental hip disorders. The objective of surgical treatment of FAI is to improve symptoms and reduce further damage to the joint.

FAI, a recently recognized condition, arises from an anatomical mismatch between the head of the femur and the acetabulum, causing compression of the labrum or articular cartilage during flexion. The mismatch can arise from subtle morphologic alterations in the anatomy or orientation of the ball-and-socket components (for example, a bony prominence at the head-neck junction or acetabular overcoverage) with articular cartilage damage initially occurring from abutment of the femoral neck against the acetabular rim, typically at the anterosuperior aspect of the acetabulum. Although hip joints can posses the morphologic features of FAI without symptoms, FAI may become pathologic with repetitive movement and/or increased force on the hip joint. High-demand activities may also result in pathologic impingement in hips with normal morphology.

Two types of impingement, known as cam impingement and pincer impingement, may occur alone or more frequently together. Cam impingement is associated with an asymmetric or nonspherical contour of the head or neck of the femur jamming against the acetabulum, resulting in cartilage damage and delamination (detachment from the subchondral bone). Deformity of the head/neck junction that looks like a pistol grip on radiographs is associated with damage to the anterosuperior area of the acetabulum. Symptomatic cam impingement is found most frequently in young male athletes. Pincer impingement is associated with overcoverage of the acetabulum and pinching of the labrum, with pain more typically beginning in women of middle age. In cases of isolated pincer impingement, the damage may be limited to a narrow strip of the acetabular cartilage. It has been proposed that impingement with damage to the labrum and/or acetabulum is a causative factor in the development of hip osteoarthritis, and that as many as half of cases currently categorized as primary osteoarthritis may have an etiology of FAI.

Previously, access to the joint space was limited and treatment consisted primarily of debridement and/or labral reattachment. A technique for hip dislocation with open osteochondroplasty that preserved the femoral blood supply was reported by Ganz and colleagues in 2001. Visualization of the entire joint with this procedure led to the identification and acceptance of FAI as an etiology of cartilage damage (the association between abnormal femoral head/neck morphology and early-age-onset osteoarthritis had been described earlier by others) and the possibility of correcting the abnormal femoroacetabular morphology. Open osteochondroplasty of bony abnormalities and treatment of the symptomatic cartilage defect is considered the gold standard for complex bony abnormalities. However, open osteochondroplasty is invasive, requiring transection of the greater trochanter (separation of the femoral head from the femoral shaft) and dislocation of the hip joint to provide full access to the femoral head and acetabulum. In addition to the general adverse effects of open surgical procedures, open osteochondroplasty with dislocation has been associated with non-union, and neurologic and soft tissue lesions. Less invasive hip arthroscopy and an arthroscopy-assisted mini-approach were adapted from the open approach by 2004. Arthroscopy requires specially designed instruments and is considered to be more technically difficult due to reduced visibility and limited access to the joint space. Advanced imaging techniques, including computed tomography and fluoroscopy, have been utilized to improve visualization of the 3-dimensional head/neck morphology during arthroscopy.

The recognition and treatment of FAI has also brought attention to the possibility of cam-type FAI after slipped capital femoral epiphysis (SCFE). The standard treatment for SCFE is stabilization across the physis by in-situ pinning, although it is not uncommon for patients with SCFE to develop premature osteoarthritis requiring total hip arthroplasty within 20 years. Treatments being evaluated for pediatric patients with SCFE-related FAI include osteoplasty without dislocation, or with the open dislocation technique described by Ganz. The Ganz technique (capital realignment with open dislocation) is technically demanding with a steep learning curve and a high risk of complications. Therefore, early treatment to decrease impingement must be weighed against increased risk for adverse events including avascular necrosis in patients with SCFE.

It is known that surgical treatment of FAI pathology is less effective for pain reduction in patients with late stage osteoarthritis. In addition, delay in the surgical correction of bony abnormalities may lead to disease progression to the point where joint preservation is no longer appropriate. It is believed that osteoplasty of the impinging bone is needed to protect the cartilage from further damage and preserve the natural joint. If FAI morphology is shown to be an etiology of osteoarthritis, a future strategy to reduce the occurrence of idiopathic hip osteoarthritis could be early recognition and treatment of FAI before cartilage damage occurs.

 

POLICY

 Open or arthroscopic treatment of femoroacetabular impingement may be medically necessary when all of the following conditions have been met:

Age

  • Adolescent patients should be skeletally mature with documented closure of growth plates (e.g., 15 years or older). Adult patients should be too young to be considered an appropriate candidate for total hip arthroplasty or other reconstructive hip surgery (e.g., younger than 55 years).

Symptoms

  • Moderate-to-severe hip pain that is worsened by flexion activities (e.g., squatting or prolonged sitting) that significantly limits activities; AND
  • Unresponsive to conservative therapy for at least 3 months (including activity modifications, restriction of athletic pursuits and avoidance of symptomatic motion); AND
  • Positive impingement sign on clinical examination (pain elicited with 90 degrees of flexion and internal rotation and adduction of the femur).

Imaging

  • Morphology indicative of cam or pincer-type FAI, e.g., pistol-grip deformity, femoral head-neck offset with an alpha angle greater than 50 degrees, a positive wall sign, acetabular retroversion (overcoverage with crossover sign), coxa profunda or protrusion, or damage of the acetabular rim; AND
  • High probability of a causal association between the FAI morphology and damage, e.g., a pistol-grip deformity with a tear of the acetabular labrum and articular cartilage damage in the anterosuperior quadrant; AND
  • No evidence of advanced osteoarthritis, defined as Tonnis grade II or III, or joint space of less than 2 mm; AND
  • No evidence of severe (Outerbridge grade IV) chondral damage.

Treatment of FAI is considered investigational in all other situations.

 

POLICY EXCEPTIONS

None

 

POLICY GUIDELINES

 If femoroacetabular impingement (FAI) morphology is identified, patients should be advised not to play aggressive sports. No more frequent than annual follow-up with magnetic resonance (MR) arthrography may be indicated for FAI morphology to evaluate cartilage changes before damage becomes severe. It should be noted that current imaging techniques limit the early identification of cartilage defects, whereas delay in the surgical correction of bony abnormalities may lead to disease progression to the point at which joint preservation is no longer appropriate. Confirmation of subtle FAI morphology may require 3-D computed tomography. Some clinicians may also use local anesthetic injection into the joint to assist in confirming FAI pathology.

Treatment of FAI should be restricted to centers experienced in treating this condition and staffed by surgeons adequately trained in techniques addressing FAI. Because of the differing benefits and risks of open and arthroscopic approaches, patients should make an informed choice between the procedures.

Some patients may require a second procedure if they have persistent or recurrent symptoms and meet the criteria for treatment of FAI. Published studies indicate that not all sources of impingement may have been identified prior to surgery, and those that had been identified may not have been adequately treated. The risk of needing an additional surgical procedure can be reduced by intra-operative assessment of impingement after bone debridement and reshaping.

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member’s specific benefit plan language.

There are no specific CPT codes for these procedures. The procedures will likely be coded using unlisted CPT codes such as code 27299 (unlisted procedure, pelvis or hip joint) or code 29999 (unlisted procedure, arthroscopy). Codes such as 29862 (arthroscopy, hip, surgical; with debridement/shaving of articular cartilage [chondroplasty], abrasion arthroplasty, and/or resection of labrum) and 27151(osteotomy, iliac, acetabular or innominate bone; with femoral osteotomy) might also be used.

There is also no specific ICD-9-CM diagnosis code for FAI. It might be coded using an unspecified code such as 719.95 (unspecified disorder of joint, pelvic region and thigh).

 

POLICY HISTORY

 6/1/2009: Policy added

7/16/2009: Approved by Medical Policy Advisory Committee (MPAC)

05/28/2010:  Policy description and guidelines updated regarding FAI treatment approaches, morphology, and pathology. Policy statement unchanged.

07/29/2011: Policy reviewed; no changes.

07/17/2012: Policy reviewed; no changes.

 

SOURCES

   Blue Cross & Blue Shield Association policy # 7.01.118

 

CODE REFERENCE

 This is not intended to be a comprehensive list of codes. Some covered procedure codes have multiple descriptions.

The code(s) listed below are ONLY covered if the procedure is performed according to the "Policy" section of this document. 

Covered Codes 

Code Number

Description

CPT

27299

Unlisted procedure, pelvis or hip joint

29999Unlisted procedure, arthroscopy

ICD-9 Procedure

 

 

ICD-9 Diagnosis

719.95

Unspecified disorder of joint, pelvic region and thigh

 

 

 

 

HCPCS

 

 

 

 

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