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. This decreased clearance between the femoral neck and the hip socket results in development of bone spurs, cartilage breakdown, pain, and decreased joint mobility. Symptoms of impingement typically occur in young to middle-aged active adults prior to the onset of advanced 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 future damage to the joint.
POLICY
Open or arthroscopic treatment of femoroacetabular impingement is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Surgical treatment of femoroacetabular impingement in all other situations is considered investigational.
MEDICAL APPROPRIATENESS
Open or arthroscopic treatment of femoroacetabular impingement is considered medically appropriate if ALL of the following criteria are met:
Skeletal maturity with documented closure of growth plates
Moderate-to-severe hip pain that is worsened by flexion activities (e.g., squatting or prolonged sitting) that significantly limits activities
Unresponsive to conservative therapy for at least 3 months (including activity modifications, restriction of athletic pursuits and avoidance of symptomatic motion)
Positive impingement sign on clinical examination (pain elicited with 90 degrees of flexion and internal rotation and adduction of the femur)
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 [over coverage with crossover sign]), coxa profunda or protrusion, or damage of the acetabular rim
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 TÖNNIS grade II or III, or joint space of less than 2 mm
No evidence of severe chondral damage (Outerbridge grade IV)
IMPORTANT REMINDERS
Any specific products referenced in this policy are just examples and are intended for illustrative purposes 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. These examples are contained in the parenthetical e.g. statement.
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan or government program (e.g., TennCare), the express terms of the health plan or government program will govern.
ADDITIONAL INFORMATION
TÖNNIS Classification of Osteoarthritis by Radiographic Changes
GRADE |
DESCRIPTION |
0 |
No signs of osteoarthritis |
1 |
Mild: Increased sclerosis, slight narrowing of the joint space, no or slight loss of head sphericity |
2 |
Moderate: Small cysts, moderate narrowing of the joint space, moderate loss of head sphericity |
3 |
Severe: Large cysts, severe narrowing or obliteration of the joint space, severe head deformity |
There is a lack of evidence to evaluate the effect of surgical treatment in other conditions to improve acute and chronic pain or health outcomes.
SOURCES
BlueCross BlueShield Association. Evidence Positioning System. (5:2023). Surgical treatment of femoroacetabular impingement. (7.01.118). Retrieved November 16, 2023 from www.bcbsaoca.com/eps/. (52 articles and/or guidelines reviewed)
Dwyer, T., Whelan, D., Shah, P.S., Ajrawat, P., Hoit, G., & Chahal, J. (2020). Operative versus nonoperative treatment of femoroacetabular impingement syndrome: A meta-analysis of short-term outcomes. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 36 (1), 263-273. Abstract retrieved September 8, 2021 from PubMed database.
Ferreira, G.E., O'Keeffe, M., Maher, C.G., Harris, I., Kwok, W., Peek, A., & Zadro J. (2020). The effectiveness of hip arthroscopic surgery for the treatment of femoroacetabular impingement syndrome: A systematic review and meta-analysis. Journal of Science and Medicine in Sport, doi: 10.1016/j.jsams.2020.06.013. (Level 2 evidence)
Harris, J., Erickson, B., Bush-Joseph, C., & Nho, S. (2013). Treatment of femoroacetabular impingement: a systematic review. Current Reviews in Musculoskeletal Medicine, 6, 207-218. (Level 2 evidence)
Khan, M., Habib, A., de Sa, D., Larson, C. M., Kelly, B. T., Bhandari, M., et al. (2016). Arthroscopy up to date: Hip femoroacetabular impingement. Arthroscopy, 32 (1), 177-189. Abstract retrieved February 4, 2016 from PubMed database.
Lynch, T. S., Minkara, A., Aoki, S., Bedi, A., Bharam, S., Clohisy, J., et al. (2020). Best practice guidelines for hip arthroscopy in femoroacetabular impingement: results of a delphi process. The Journal of the American Academy of Orthopaedic Surgeons, 28 (2), 81–89, doi: 10.5435/JAAOS-D-18-00041. Abstract retrieved October 31, 2022 from PubMed database.
National Institute for Health and Clinical Excellence. (2011, September). Open femoro-acetabular surgery for hip impingement syndrome. Retrieved October 3, 2011 from http://www.nice.org.
National Institute for Health and Clinical Excellence. (2011, September). Arthroscopic femoro-acetabular surgery for hip impingement syndrome. Retrieved October 3, 2011 from http://www.nice.org.
Nwachukwu, B., Rebolledo, B., McCormick, F., Rosas, S., Harris, J., & Kelly, B. (2016). Arthroscopic versus open treatment of femoroacetabular impingement: a systematic review of medium-to long-term outcomes. American Journal of Sports Medicine, 44 (4), 1062-1068. Abstract retrieved October 18, 2017 from PubMed database.
O’Connor, M., Steini, G.K., Padaki, A.S., Duchman, K.R., Westermann, R.W., & Lynch, T.S. (2019) Outcomes of revision hip arthroscopic surgery: A systematic review and meta-analysis. American Journal of Sports Medicine, doi: 10.1177/0363546519869671. Abstract retrieved November 8, 2019 from PubMed database.
Zhang, D., Chen, L., & Wang, G. (2016). Hip arthroscopy versus open surgical dislocation for femoroacetabular impingement. Medicine, 95 (41), e5122. (Level 2 evidence)
Zhu, Y., Su, P., Xu, T., Zhang, L., & Fu, W. (2022). Conservative therapy versus arthroscopic surgery of femoroacetabular impingement syndrome (FAI): a systematic review and meta-analysis. Journal of Orthopaedic Surgery and Research, 17 (1), 296. (Level 1 evidence)
ORIGINAL EFFECTIVE DATE: 2/12/2012
MOST RECENT REVIEW DATE: 1/11/2024
ID_BA
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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