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Date Printed: August 18, 2017: 10:18 AM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

02-20000-35

Original Effective Date: 07/15/08

Reviewed: 08/28/14

Revised: 10/15/16

Subject: Femoroacetabular Impingement (FAI) Syndrome Surgery (Open or Arthroscopic)

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Update  
           

DESCRIPTION:

Femoroacetabular impingement (FAI), a condition that has been recently recognized, is an anatomical mismatch between the head of the femur and the acetabulum resulting in 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 headneck 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.

There are three types of FAI: pincer, cam, and combined impingement.

  1. Pincer. This type of impingement occurs because extra bone extends out over the normal rim of the acetabulum. The labrum can be crushed under the prominent rim of the acetabulum.
  2. Cam. In cam impingement the femoral head is not round and cannot rotate smoothly inside the acetabulum. A bump forms on the edge of the femoral head that grinds the cartilage inside the acetabulum.
  3. Combined. Combined impingement just means that both the pincer and cam types are present.

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.

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.

Femoroacetabular impingement is often accompanied by labral tears, requiring surgical treatment. The accepted standard treatment for labral tears is debridement (i.e., resection). Other techniques of repair (i.e., shaving of the frayed labral, repair involving stitching the torn labral to the acetabular rim, repairs with or without grafting) in place of debridement, have been investigated and continue to evolve.

POSITION STATEMENT:

Open or arthroscopic surgical treatment of femoroacetabular impingement syndrome, with or without labral repair, meets the definition of medical necessity when ALL of the following criteria have been met:

1. Age

Candidates should be skeletally mature with documented closure of growth plates (e.g., 15 years or older).

2. 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 is demonstrated on clinical examination (pain elicited with 90 degrees of flexion and internal rotation and adduction of the femur).

3. 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 protrusio, 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.

Labral debridement (resection) or labral repair (refixation or reattachment) when performed as a stand alone surgical procedure without a diagnosis of FAI meets the definition of medical necessity.

BILLING/CODING INFORMATION:

CPT Coding:

29914

Arthroscopy, hip, surgical; with femoroplasty (i.e., treatment of cam lesion)

29915

Arthroscopy, hip, surgical; with acetabuloplasty (i.e., treatment of pincer lesion)

29916

Arthroscopy, hip, surgical; with labral repair

There are no specific CPT codes for the open treatment of FAI. The procedure might be coded using code 27299 (unlisted procedure, pelvis or hip joint).

There is no specific ICD-10 diagnosis code that describes femoroacetabular impingement syndrome or labral tears of the hip.

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

No National Coverage Determination (NCD) and/or Local Coverage Determination (LCD) were found at the time of the last guideline reviewed date.

DEFINITIONS:

Outerbridge grades:

Tonnis classification of osteoarthritis by radiographic changes:

RELATED GUIDELINES:

Hip Arthroplasty, 02-20000-50

Hip Arthroscopy and Open, Non-Arthroplasty Hip Repair, 02-20000-55

OTHER:

None applicable.

REFERENCES:

  1. American Academy of Orthopedic Surgeons (AAOS) Website. AAOS Now. Hip arthroscopy for pediatric FAI safe, reliable. June 2008.
  2. American Academy of Orthopedic Surgeons (AAOS) Website. AAOS Now. SCFE leads to symptomatic FAI. July 2009.
  3. American Academy of Orthopedic Surgeons (AAOS) Website. AAOS Now. Early screening is vital for FAI. Feb 2009.
  4. American Academy of Orthopedic Surgeons (AAOS) Website. Orthoinfo. Femoroacetabular impingement (FAI). September 2010. Accessed 07/03/14.
  5. Blue Cross and Blue Shield Association Medical Policy Reference Manual. Surgical Treatment of Femoroacetabular Impingement, (05/22/14).
  6. Brigham and Women’s Hospital. Department of Rehabilitation Services. Standard of Care. Hip Labral Tears. [Cited June 01, 2010].
  7. ClinicalTrials.gov; Prevalence of Femoroacetabular Impingement in Asymptomatic Patients. NCT00606047. (Updated 01/31/08).
  8. Espinosa N, Beck M, Rothenfluh DA, Ganz R, Leunig M. Treatment of femoro-acetabular impingement: preliminary results of labral refixation. Surgical technique. J Bone Joint Surg Am. 2007 Mar; 89 Suppl 2 Pt. 1:36-53.
  9. Femoroacetabular Impingement (FAI). Orland Park Orthopedics. Center for Sports Medicine. 16450 S. 104th Avenue, Orland Park, IL 60467. [Cited June 01, 2010]
  10. Ganz R, Leunig M, Leunig-Ganz K, HarrisWH. The etiology of osteoarthritis of the hip: an integrated mechanical concept. Clin Orthop Relat Res. 2008 Feb;466(2):264-72.
  11. Groh MM, Herrera J. A comprehensive review of hip labral tears. Curr Rev Musculoskelet Med. 2009 Jun;2(2):105-17.
  12. HAYES Health Technology Brief: “Arthroscopic Hip Surgery for Femoroacetabular Impingement (FAI)” (06/21/06).
  13. Hegmann KT, editor(s). Occupational medicine practice guidelines. Evaluation and management of common health problems and functional recovery in workers. 3rd ed. Elk Grove Village (IL): American College of Occupational and Environmental Medicine; 2011. p. 1-440.
  14. James SL, Ali K, Malara F, Young D, O'Donnell J, Connell DA. MRI findings of femoroacetabular impingement. AJR Am J Roentgenol. 2006 Dec;187(6):1412-9.
  15. Kang C, Hwang DS, Cha SM. Acetabular labral tears in patients with sports injury. Clin Orthop Surg. 2009 Dec;1(4):230-5.
  16. Labral Tear of the Hip Joint. About.com: Orthopedics. [Cited June 01, 2010]
  17. Labral Tears and FAI. My Hip Space. [Cited June 01, 2010]
  18. Matsuda, DK. Arthroscopic surgery for hip impingement: It works for me; A surgeon’s perspective – from both sides of the scalpel. American Academy of Orthopedic Surgeons (AAOS) Now; June 2008 Issue.
  19. Mayoclinic.com. Hip labral Tear. [Cited June 01, 2010]
  20. Mayo Clinic - Hip Arthroscopy in Young Adults with Femoroacetabular Impingement. Accessed 07/24/13.
  21. Meldrum, Russel Femoroacetabular Impingement (FAI).. [Cited June 01, 2010].
  22. National Health Library; Trauma and Orthopaedics Specialist Library. Surgery for femoroacetabular impingement. Editorial written for the 2008 National Knowledge Week on Osteoarthritis; Professor Damian Griffin, contributing writer. (10/01/07)
  23. National Institute for Health and Clinical Excellence (NICE), Interventional Procedure Guidance 203, Open femoro-acetabular surgery for hip impingement syndrome, (01/07). (replaced by IPG 403)
  24. National Institute for Health and Clinical Excellence (NICE), Interventional Procedure Guidance 403, Open femoro–acetabular surgery for hip impingement syndrome, (07/11).
  25. National Institute for Health and Clinical Excellence (NICE), Interventional procedure guidance 408, Arthroscopic femoro–acetabular surgery for hip impingement syndrome (09/2011).
  26. National Library for Health. Trauma and Orthopaedics Specialist Library. Surgery for femoroacetabular impingement. 2007
  27. Nord RM, Meislin RJ. Hip arthroscopy in adults. Bull NYU Hosp Jt Dis. 2010;68(2):97-102.
  28. Orthopaedia – Femoroacetabular impingement. In: Orthopaedia – Collaborative Orthopaedic Knowledgebase. Created May 30, 2007 05:25 by Michael Taunton, Last modified Oct 22, 2008 12:55 ver.30.
  29. Peters, Christopher L, Erickson, Jill A. Treatment of Femoroacetabular Imipingement with Surgical Dislocation and Debridement in Young Adults. J or Bone and Joint Surgery. 2006; 88:1735-1741.
  30. Philippon MJ, Schroder e Souza BG, Briggs KK. Labrum: resection, repair and reconstruction sports medicine and arthroscopy review. Sports Med Arthrosc. 2010 Jun;18(2):76-82.
  31. Philippon MJ, Weiss DR, Kuppersmith DA, Briggs KK, Hay CJ. Arthroscopic labral repair and treatment of femoroacetabular impingement in professional hockey players. Am J Sports Med. 2010 Jan;38(1):99-104.
  32. Philippon, MJ, et al. Outcomes following hip arthroscopy for femoroacetabular impingement with associated chondrolabral dysfunction. J or Bone and Joint Surgery – British Volume, Jan 2009, Vol 91-B, Issue 1, 16-23.
  33. Sampson, TG. Arthroscopic Treatment of Femoroacetabular Impingement; Techniques in Orthopaedics. (2005) 20:56-62.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 08/28/14.

GUIDELINE UPDATE INFORMATION:

07/15/08

New Medical Coverage Guideline.

05/15/09

Scheduled review; Description section revised; no change in position statement; references updated.

07/15/10

Scheduled review; Description and Position Statement sections updated to include descriptive information and criteria regarding labral tear repairs; coding section updated; references updated.

09/15/10

Unscheduled review of position statement regarding labral tear repair; Position Statement unchanged.

01/01/11

Annual HCPCS coding update; added 29914, 29915, and 29916.

09/15/11

Annual review; position statement revised; references updated; formatting changes.

08/15/12

Scheduled review; position statement revised regarding labral tear repairs; references updated.

09/15/13

Scheduled review; position statement criteria revised regarding “age”; Program Exceptions section updated; references updated.

09/15/14

Annual review; position statement unchanged, references updated.

11/01/15

Revision: ICD-9 Codes deleted.

10/15/16

Revision: deleted CPT code 29862. [Refer to MCG 02-20000-55, Hip Arthroscopy and Open, Non-Arthroplasty Hip Repair].

Date Printed: August 18, 2017: 10:18 AM