Open or arthroscopic treatment of femoroacetabular impingement may be medically necessary when all of the following conditions have been met:
Age
Candidates should be skeletally mature with documented closure of growth plates (eg, ≥15 years of age).
Symptoms
Moderate-to-severe hip pain worsened by flexion activities (eg, 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 on clinical examination (pain elicited with 90° of flexion and internal rotation and adduction of the femur).
Imaging
Morphology indicative of cam or pincer femoroacetabular impingement (eg, pistol-grip deformity, femoral head-neck offset with an alpha angle >50°, a positive wall sign, 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 femoroacetabular impingement morphology and damage (eg, 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 grade 2 or 3, or joint space of less than 2 mm; AND
No evidence of severe (Outerbridge grade IV) chondral damage.
Treatment of femoroacetabular impingement is considered investigational in all other situations.
