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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 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 criterion 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.
An association between FAI and athletic pubalgia, sometimes called sports hernia, has been proposed. Athletic pubalgia is an umbrella term for a large variety of musculoskeletal injuries involving attachments and/or soft tissue support structures of the pubis (see Surgery for Athletic Pubalgia medical policy). It is believed that if FAI presents with limitations in hip range of motion, compensatory patterns during athletic activity may lead to increased stresses involving the abdominal obliques, distal rectus abdominis, pubic symphysis, and adductor musculature. The condition is more common in men than in women and is associated with sports in which high speed twisting of the hip and pelvis occur (eg, football, hockey). Under surgical exploration, a variety of musculotendinous defects, nerve entrapments, and inflammatory conditions have been observed.
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.
POLICYOpen or arthroscopic treatment of femoroacetabular impingement may be medically necessary when all of the following conditions have been met:
Treatment of FAI is considered investigational in all other situations.
POLICY GUIDELINESIf 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.
Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Nervous/Mental Conditions, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:
A. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and
B. appropriate with regard to standards of good medical practice; and
C. not solely for the convenience of the Member, his or her Provider; and
D. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.
For the definition of Medically Necessary, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.
Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member’s specific benefit plan language.
POLICY HISTORY6/1/2009: 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.
11/01/2013: Age section of policy statement revised to remove the age restriction for adults and to clarify the age restrictions for adolescents. Statement previously stated: 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). Added CPT codes 29914, 29915, and 29916 to the Code Reference section.
07/11/2014: Policy reviewed; description updated regarding an association between FAI and athletic pubalgia. Policy statements unchanged.
08/27/2015: Code Reference section updated for ICD-10. Added ICD-9 procedure code 81.40 to the Code Reference section.
09/29/2015: Policy description updated to add medical policy link. Policy statements unchanged. Policy Guidelines section updated to add medically necessary and investigative definitions.
05/31/2016: Policy number added.
SOURCESBlue Cross & Blue Shield Association policy # 7.01.118
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.