Femoroacetabular Impingement Surgery

Medical Policy: 07.01.42 
Original Effective Date: August 2008 
Reviewed: December 2011 
Revised: June 2009 

Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary based on contract, and individual member benefits must be verified. Wellmark determines medical necessity only if the benefit exists and no contract exclusions are applicable. This medical policy may not apply to FEP. Benefits are determined by the Federal Employee Program.

This Medical Policy 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 will be reviewed regularly and be updated as scientific and medical literature becomes available.

Description: 

Femoroacetabular Impingement (FAI), previously called acetabular rim syndrome or cervicoacetebular impingement, is a recently recognized pathological condition of the hip affecting young and middle aged active patients and athletes. FAI 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 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. Pain is described as an aching mainly in the groin, or hip, which can sometimes spread into the thigh, buttock or lower back and can become chronic. The pain can be associated with sports activities, prolonged walking, or prolonged sitting. 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. It is also common to have cartilage damage, loss of range of motion and disability. The literature indicates an association with FAI and progressive osteoarthritis of the hip.

Types of FAI include:

• 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).
  • Most common in young male athletes
  • Deformity of the head-neck junction (femoral cause) is associated with damage to the anterosuperior area of the acetabulum that looks like a pistol grip on radiographs.
• Pincer impingement
  • Is associated with overcoverage of the acetabulum and pinching of the labrum (acetabular cause)
  • Most common  in middle-aged active women, with pain more typically beginning in this group.
  • 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 the cases currently categorized as primary osteoarthritis may have an etiology of FAI.
• Mixed pincer and cam impingement
  • Is the most common type of FAI

The main surgical treatment goal is to improve motion at the hip joint and lessen the femoral force against the acetabular rim. Based on the type of FAI, surgical techniques may include procedures such as hip arthroplasty, labral debridement or repair/refixation, proximal femoral osteoplasty, or acetabulum rim trimming. Benefits of open versus arthroscopic procedures for FAI are being discussed in the literature.

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.

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Prior Approval: 

Not applicable

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Policy: 

Open or arthroscopic treatment of femoroacetabular impingement may be medically necessary when ALL of the following conditions have been met:

Age

• 15 - 55 years old. (Adolescent patients should be skeletally mature with documented closure of growth plates.)

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 care for at least 3 months (including physical therapy; activity modifications; restriction of athletic, recreational or aggravating lifestyle pursuits; and avoidance of symptomatic motion); AND
• Positive impingement sign on clinical examination (pain elicited with 90 degrees of flexion and internal rotation and adduction of the femur).

Imaging

• Morphology indicative of cam or pincer-type FAI, e.g., pistol-grip deformity, or femoral head-neck offset with an alpha angle greater than 50 degrees, or a positive wall sign, or acetabular retroversion (overcoverage with crossover sign), coxa profunda or protrusion, 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 Tönnis Classification* Grade II or III, or joint space of less than 2 mm; AND
• No evidence of severe (Outerbridge** grade IV) chondral damage.

Treatment of FAI is considered investigational if all of the above criteria are not met.

*Tönnis Classification of Osteoarthritis by Radiographic Changes

Source: Orthopaedia - Collaborative Orthopaedic Knowledgebase.

**Classification of Articular Cartilage Lesions by Severity

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Procedure Codes and Billing Guidelines: 

• To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
• 27151 Osteotomy, iliac, acetabular or innominate bone; with femoral osteotomy
• 29862 Arthroscopy, hip, surgical; with debridement/shaving of articular cartilage (chondroplasty), abrasion arthroplasty, and/or resection of labrum
• 29914 Arthroscopy, hip, surgical; with femoroplasty (ie, treatment of cam lesion)
• 29915 Arthroscopy, hip, surgical; with acetabuloplasty (ie, treatment of pincer lesion)
• 29916 Arthroscopy, hip, surgical; with labral repair

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Selected References: 

• Griffin D. Trauma and Orthopaedics Specialist Library – Surgery for femoroacetabular impingement. National Library for Health. 2007. Available at: http://www.library.nhs.uk/trauma_orthopaedics/viewResource.aspx?resID=269337&code=a970c70c0377dad739c5ab0421d420d3
• Khanduja V, Villar RN. The arthroscopic management of femoroacetabular impingement. Knee Surg Sports Traumatol Arthrosc 2007;15(8):1035-1040.
• National Institute for Health and Clinical Excellence (NICE). Arthroscopic femoro-acetabular surgery for hip impingement syndrome. March 2007. Available at: www.nice.org.uk/IPG213distributionlist
• National Institute for Health and Clinical Excellence (NICE). Open femoro-acetabular surgery for hip impingement syndrome. January 2007. Available at: www.nice.org.uk/IPG203distributionlist
• Parvizi J, Leuning M, Ganz R. Femoroacetabular impingement. J Am Acad Orthop Surg  2007 Sep;15(9):561-70.
• Zebala LP, Scjpemecker PL, Clohisy JC. Anterior femoroacetabular impingement: a diverse disease with evolving treatment options. Iowa Ortho J 2007;27:71-81.
• ECRI. Surgical Treatment of Femoroacetabular Impingement. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2008 June 11. 12 p. (ECRI Hotline Response). Also available: http://www.ecri.org.
• Larson CM, Giveans MR. Arthroscopic management of femoroacetabular impingement: early outcomes measures. Arthroscopy 2008;24(5):540-546.
• Standaert CJ, Manner PA, Herring SA. Expert Opinion and Controversies in Musculoskeletal and Sports Medicine: Femoroacetabular Impingement.  Arch Phys Med Rehabil 2008 May;89(5):890-3.
• Orthopaedia - Hip dysplasia. In: Orthopaedia - Collaborative Orthopaedic Knowledgebase. Created Aug 16, 2007 19:03 by Michael Taunton, Last modified Mar 17, 2008 17:01 ver.10. Retrieved 2009-06-03, from http://www.orthopaedia.com/x/HYIe.
• The Medical Policy Reference Manual (MPRM) developed by the Blue Cross Blue Shield Association Health Management Systems, based on Technology Evaluation Center (TEC) criteria.
• ECRI Institute. Surgical treatment of femoroacetabular impingement. Plymouth Meeting (PA): ECRI Institute; 2009 Nov 16. 8p. [ECRI hotline response]. Also available: http://www.ecri.org.
• National Institute for Health and Clinical Excellence (NICE). Open femoro-acetabular surgery for hip impingement syndrome. Interventional Procedure Guidance 403. London, UK: NICE; July 2011.
• National Institute for Health and Clinical Excellence (NICE). Arthroscopic femoro-acetabular surgery for hip impingement syndrome. Interventional Procedure Guidance 408. London, UK: NICE; September 2011.
• Matsuda DK, Carlisle JC, Arthurs SC, et al. Comparative systematic review of the open dislocation, mini-open, and arthroscopic surgeries for femoroacetabular impingement. Arthroscopy. 2011 Feb;27(2):252-69    

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Policy History: 

Date                                        Reason                               Action

December 2010                      Annual review                     Policy renewed

December 2011                      Annual review                     Policy renewed

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