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Date Printed: December 17, 2017: 04:22 PM

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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.

02-20000-55

Original Effective Date: 10/15/16

Reviewed: 09/22/16

Revised: 00/00/00

Next Review: No Longer Scheduled for Routine Review (NLR)

Subject: Hip Arthroscopy and Open, Non-Arthroplasty Hip Repair

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 Updates      
           

DESCRIPTION:

This guideline describes the indications for and surgical uses of arthroscopy in the hip as well as open, non-arthroplasty hip repair procedures. Arthroscopy introduces a fiberoptic camera into the hip joint (arthroscopy) and surrounding extra-articular areas (endoscopy) through a small incision for diagnostic purposes. Other tools may then be introduced to remove, repair, or reconstruct intra-articular and extra-articular pathology. Surgical indications are based on relevant clinical symptoms, physical exam, radiologic findings, and response to non-operative, conservative management when medically appropriate.

POSITION STATEMENT:

Arthroscopy for Synovectomy, Biopsy, or Removal of Loose or Foreign Body

Arthroscopic synovectomy, biopsy, removal of loose or foreign body, or a combination of these procedures meets the definition of medical necessity when the following criteria are met:

• Radiographic evidence of acute, post-traumatic, intra-articular foreign body or displaced fracture fragment

OR

• When ALL of the following criteria are met:

• Hip pain associated with grinding, catching, locking, or popping, for at least 12 weeks not improved with conservative, non-operative care*, AND

• Physical exam finding confirms painful hip with limited range of hip motion, AND

• Radiographs, CT and/or MRI reveal synovial proliferation, calcifications, nodularity, inflammation, pannus, or loose body

Shaving or debridement of articular cartilage (chondroplasty), and/or abrasion arthroplasty

There are no clinical indications for performing an independent debridement procedure within the hip. Debridement should always be combined or secondary to another procedure, and is primarily performed within FAI procedures.

Extra-articular (Endoscopic) Hip Surgery

Extra-articular hip applications meets the definition of medical necessity when used to minimize symptoms of:

• Internal snapping hip (internal coxa saltans, iliopsoas tendonitis, snapping iliopsoas)

• Iliopsoas tendon at iliopectineal eminence or anterior inferior iliac spine

• External snapping hip (external coxa saltans, snapping iliotibial band, iliotibial band at greater trochanter)

• Partial tear of proximal hamstring with or without bursitis

• Proximal hamstring, sciatic neurolysis, ischiofemoral decompression (for ischiofemoral impingement)

• Anterior inferior iliac spine (subspine) decompression for subspine impingement (there are 3 types of anterior inferior iliac spine):

• Type 1: small, tip does not extend to sourcil (type 1 typically never requires surgical decompression)

• Type 2: medium, tip extends down to sourcil (most type 2 typically requires surgical decompression)

• Type 3: large, tip extends down below sourcil (type 3 typically always requires surgical decompression)

Extra-articular (endoscopic) hip surgery may meet the definition of medical necessity when the criteria listed below are met.

• Painful snapping sensation around the hip joint related to activity, caused by the iliotibial tract over the greater trochanter or bursa (external snapping hip), and/or the iliopsoas tendon over medial bony prominence or bursa (internal snapping hip), unresponsive to non-operative care*

OR

• Pain and tenderness at the greater or lesser trochanter related to activity, due to bursal inflammation, tendinosis and/or tendinitis, or tear of the tendon (gluteus medius or minimus), unresponsive to non-operative care*, AND

• At least 6 months of activity modification, supervised physical therapy, NSAIDS, and/or corticosteroid injection, AND

• Physical exam findings align with patient symptoms and has at least one or more of the following:

• Limp or painful ambulation

• Tenderness and/or crepitus to palpation

• Visible, audible, or palpable snapping at the greater trochanter or pelvic brim

• Pain and/or weakness with active or resisted motion of the hip

• Pain relief with diagnostic local anesthetic injection

*Non-Operative Treatment

Conservative, non-operative care* is defined as a combination of two or more of the following:

• Rest or activity modifications/limitations

• Ice/heat

• Protected weight bearing

• Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, analgesics

• Brace/orthosis

• Physical therapy modalities

• Supervised home exercise

• Weight optimization

• Injections (e.g., cortisone)

BILLING/CODING INFORMATION:

CPT Coding:

29860

Arthroscopy, hip, diagnostic with or without synovial biopsy (separate procedure)

29861

Arthroscopy, hip, surgical; with removal of loose body or foreign body

29862

Arthroscopy, hip, surgical; with debridement/shaving of articular cartilage (chondroplasty), abrasion arthroplasty, and/or resection of labrum

29863

Arthroscopy, hip, surgical; with synovectomy

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 review date.

DEFINITIONS:

No guideline specific definitions apply.

RELATED GUIDELINES:

Femoroacetabular Impingement (FAI) Syndrome Surgery (Open or Arthroscopic), 02-20000-35

Hip Arthroplasty, 02-20000-50

OTHER:

None applicable.

REFERENCES:

  1. Bhatia S, Chahla J, Dean CS, Ellman MB. Hip Labral Reconstruction: The "Kite Technique" for Improved Efficiency and Graft Control. Arthrosc Tech. 2016 Apr 4;5(2):e337-42.
  2. Cvetanovich GL, Heyworth BE, Murray K, Yen YM, Kocher MS, Millis MB. Hip arthroscopy in patients with recurrent pain following Bernese periacetabular osteotomy for acetabular dysplasia: operative findings and clinical outcomes. J H Preserv Surg. 2015 Jun 13;2(3):295-302.
  3. Egerton T, Hinman RS, Takla A, Bennell KL, O’Donnell J. Intraoperative Cartilage Degeneration Predicts Outcome 12 Months After Hip Arthroscopy. Clinical Orthopaedics and Related Research. 2013 Feb;471(2):593.
  4. Ferro FP, Philippon MJ. Arthroscopy provides symptom relief and good functional outcomes in patients with hip synovial chondromatosis. J Hip Preserv Surg. 2015 Jul 13;2(3):265-71.
  5. Filbay SR, Kemp JL, Ackerman IN, Crossley KM. Quality of life impairments after hip arthroscopy in people with hip chondropathy. J Hip Preserv Surg. 2016 Feb 26;3(2):154-64.
  6. Hwang JT, Lee WY, Kang C, Hwang DS, Kim DY, Zheng L. Usefulness of Arthroscopic Treatment of Painful Hip after Acetabular Fracture or Hip Dislocation. Clin Orthop Surg. 2015 Dec;7(4):443-8.
  7. InterQual® 2014. CP: Procedures. Arthroscopy, Diagnostic, +/- Synovial Biopsy, Hip.
  8. InterQual® 2014. CP: Procedures. Arthroscopy, Surgical, Hip.
  9. Jo S, Lee SH, Wang SI, Smith B, O'Donnell J. The role of arthroscopy in the dysplastic hip-a systematic review of the intra-articular findings, and the outcomes utilizing hip arthroscopic surgery. J Hip Preserv Surg. 2016 Jan 9;3(3):171-80.
  10. Newman JT, Saroki AJ, Philippon MJ. Hip arthroscopy for the management of trauma: a literature review. J Hip Preserv Surg. 2015 Jun 24;2(3):242-8.
  11. Salas AP. Radiographic and anatomic landmarks to approach the anterior capsule in hip arthroscopy. J Hip Preserv Surg. 2015 Sep 1;2(4):431-7.
  12. Sansone M, Ahldén M, Jonasson P, Thomeé C, Swärd L, Collin D, Baranto A, Karlsson J, Thomeé R. Outcome of hip arthroscopy in patients with mild to moderate osteoarthritis-A prospective study. J Hip Preserv Surg. 2015 Dec 26;3(1):61-7.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 09/22/16.

GUIDELINE UPDATE INFORMATION:

10/15/16

New Medical Coverage Guideline.

Date Printed: December 17, 2017: 04:22 PM