Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Surgical Treatment of Femoroacetabular Impingement

Policy #:11.14.23c

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.

Surgery for femoroacetabular impingement (FAI), when performed as an open or arthroscopic procedure, is considered medically necessary and, therefore, covered for individuals who have been determined by the operative surgeon to be too young to be considered an appropriate candidate for total hip arthroplasty or other reconstructive hip surgery (e.g., the lifespan of the replacement hip would require many surgeries due to wear and tear, which would be out of proportion to the individual's projected lifespan) when ALL of the following criteria are met:
  • Presence of moderate-to-severe hip pain that is worsened by flexion activities (e.g., squatting or prolonged sitting) that significantly limits activities
  • Presence of FAI symptoms that have been unresponsive to conservative therapy for at least three months
  • Presence of positive impingement sign on clinical examination (i.e., pain elicited with 90 degrees of flexion and internal rotation and adduction of the femur)
  • Presence of 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)
  • Presence of a 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)
  • No evidence of advanced osteoarthritis, defined as Tonnis grade II or III, or joint space of less than 2 mm
  • No evidence of severe (Outerbridge grade IV) chondral damage on preoperative imaging

Surgery for FAI in individuals without documented closure of growth plates is considered medically necessary and, therefore, covered for individuals who meet all of the above criteria and:
  • A pediatric orthopedist has evaluated and recommended the individual for FAI surgery.

When all of the above criteria are not met, surgery for FAI is considered experimental/investigational and, therefore, not covered because its safety and/or effectiveness cannot be established by review of the available published peer-reviewed literature.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Guidelines

Confirmation of subtle femoroacetabular impingement (FAI) morphology may require three-dimensional (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.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract. FAI is covered under the medical benefits of the Company’s products when the medical necessity criteria listed in this medical policy are met.

Description

Femoroacetabular impingement (FAI) has been recently recognized as a cause of hip pathology in which an anatomical mismatch between the head of the femur, acetabulum, or both results in impingement of the labrum or articular cartilage, often causing labral tears. FAI is characterized by abutment of the femoral neck against the acetabular rim, which may occur as a result of cam or pincer impingement, although most commonly by a mixture of both. 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 detachment from the subchondral bone. Radiographs may show a deformity of the head/neck junction that resembles a pistol grip, and damage to the anterosuperior area of the acetabulum may be present. Symptomatic cam impingement is found most frequently in young men. Pincer impingement, on the other hand, occurs when an abnormality of the acetabulum results in impingement against an often normal femoral neck. Pincer impingement is more frequently seen in athletic, middle-aged women.

FAI can encompass a variety of patterns and a wide range of deformity and degenerative severity. It is thought that FAI is a major cause of osteoarthritis (OA), but the exact relationship between OA and FAI is unclear. It is theorized that early surgical correction of the abnormal FAI morphology can delay the progression of OA.

Nonsurgical treatment options for FAI include activity modification or restriction, nonsteroidal anti-inflammatory drugs, and corticosteroid injections. Physical therapy is advocated, but some suggest that it may be counterproductive. Surgical treatments focus on clearance for hip motion by alleviating the femoral impingement against the acetabular rim. Both open and arthroscopic surgery are advocated as treatment options for individuals with FAI. The choice of procedure may vary according to disease type, patient factors, and physician expertise and preference.

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 and dislocation of the hip joint to provide full access to the femoral head and acetabulum. Complications of the open surgical procedures include non-union, neurologic, and soft tissue lesions, and the general risks associated with an open procedure. Hip arthroscopy is a new and minimally invasive method of treating individuals with FAI. Little information is available on complications directly related to the arthroscopic treatment of FAI. It is known that surgical treatment (both arthroscopic and open) of FAI pathology is less effective for pain reduction in individuals with late-stage OA. A common finding in published studies was an increased incidence of treatment failure among individuals with substantial pre-existing OA. Treatment of FAI is most effective in younger individuals who do not have OA (Tonnis grade 0 or I) or severe cartilage damage.

PEER-REVIEWED LITERATURE

An abundance of articles on FAI surgery has been published in the last few years, including five prospective/consecutive case series with over 100 hips/individuals treated for FAI who reported significant improvement in pain and activity limitations after surgery. In a 2012 review by Papalia et al., 31 studies (n = 1713 individuals) were identified that reported clinical, functional, and imaging outcomes after open or arthroscopic treatment of FAI. From extracted data, the authors concluded that arthroscopy, open surgery, and arthroscopic surgery followed by mini open surgery are comparable for functional results, biomechanics, and return to sport. Progression of OA and conversion to hip arthroplasty are dependent on preoperative status of cartilage and osteoarthritis and type of management.

In 2013, a direct comparison of arthroscopic and open treatment of FAI was reported by Zingg et al. Out of 200 study participants with FAI, 10 agreed to be randomly allocated to arthroscopy or open surgical hip dislocation, and 28 agreed to participate in the study but selected their preferred treatment. The open and arthroscopic groups were generally comparable at baseline. Arthroscopic treatment of FAI resulted in a shorter hospital stay (3 vs. 5 days) and less time off from work. The Harris hip score (HHS) was improved compared to open treatment at 6 weeks, 3 months, and 12 months. Overall, pain scores (Western Ontario and McMaster Universities Arthritis Index [WOMAC] and Visual Analog Score [VAS]) were lower with arthroscopy, reaching statistical significance on about half of the time points. Compared with the open surgical approach, the authors reported that arthroscopy resulted in morphological over-corrections at the head-neck-junction.

SUMMARY

Surgical treatment of FAI attempts to improve associated symptoms and reduce further damage to the joint. In 2011, the National Institute for Health and Clinical Excellence (NICE) issued revised guidelines on arthroscopic and open FAI surgery for hip impingement syndrome. They noted that the current evidence on the efficacy of FAI surgery was adequate in terms of symptom relief in the short and mid-term. Published studies of the open and arthroscopic procedures have a follow-up of three years or less. Therefore, long-term studies are needed to look at indicators of success, such as alteration in the natural progression to osteoarthritis, sustained pain relief, and improvement in long-term functional ability as a result of surgical treatment of FAI. However, current published studies document excellent improvement in function and a high level of patient satisfaction in the both the short and mid-term.
References


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Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

29914, 29915, 29916


THE FOLLOWING CODE IS USED TO REPRESENT OPEN FEMOROACETABULAR SURGERY: 27299



Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A

Coding and Billing Requirements



Policy History

Revisions from 11.14.23c
10/10/2018This policy was reviewed and reissued in accordance with the Company's Policy Confirmation Review track.


Effective 10/05/2017 this policy has been updated to the new policy template format.


Version Effective Date: 07/12/2013
Version Issued Date: 07/12/2013
Version Reissued Date: 10/10/2018

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