7.01.109 Surgical Treatment of Femoroacetabular Impingement
Original MPC Approval: 08/12/2009
Last Review: 09/19/2011
Last Revision: 09/19/2011
Open or arthroscopic surgery to treat femoroacetabular impingement is considered medically necessary. (See Provider Guidelines).
The following were among the resources reviewed and considered in developing this policy. By reviewing and considering the resources, CareFirst does not in any way endorse the contents thereof nor assume any liability or responsibility in connection therewith. The opinions and conclusions of the authors of these resources are their own, and may or may not be in agreement with those of CareFirst.
Bardokos, N.V., Vasconcelos, J.C., Villar, R.N. (2008). Early outcome of hip arthroscopy for femoroacetabular impingement: the role of femoral osteoplasty in symptomatic improvement. Journal of Bone and Joint Surgery British90, 1570-5
Beaulé, P.E., LeDuff, M.J., Zaragoza, E. (2007). Quality of life following femoral head-neck osteochondroplasty for femoroacetabular impingement. Journal of Bone and Joint Surgery American89, 773-9.
Beck, M., Leunig, M., Parvizi, J. et al (2004). Anterior femoroacetabular impingement: part II. Midterm results of surgical treatment. Clinical Orthopaedics and Related Research 418, 67-73.
Blue Cross and Blue Shield Association (April, 2009; updated 2010, May). Surgical Treatment of Femoroacetabular Impingement (Medical Policy 7.01.118). Chicago, IL: Author.
Botser, I., Smith, T., Nasser, R., Domb, B. (2011, February). Open surgical dislocation versus arthroscopy for femoroacetabular impingement: a comparison of clinical outcomes. Arthroscopy. 27(2):270-8.
Byrd, J.W., Jones, K.S. (2009). Arthroscopic femoroplasty in the management of cam-type femoroacetabular impingement. Clinical Orthopaedics and Related Research467, 739-46.
Hayes Medical Technology Brief (2008; updated 2011, March). Arthroscopic Hip Surgery for Femoroacetabular Impingement (FAI). July 18, 2008. Lansdale, PA: Hayes, Inc.
Larson, C.M., Giveans, M.R. (2008). Arthroscopic management of femoroacetabular impingment: early outcomes measures. Arthroscopy 24, 540-6.
Matsuda, D., Carlisle, J., Arthurs, S., et al (2011, February). Comparative systematic review of the open dislocation, mini-open, and arthroscopic surgeries for femoroacetabular impingement. Arthroscopy. 27(2):252-69.
Murphy, S., Tannast, M., Kim, Y.J. et al (2004). Debridement of the adult hip for femoroacetabular impingement: indications and preliminary clinical results. Clinical Orthopaedics and Related Research 429. 178-81.
Peters, C.L., Erickson, J.A. (2006) Treatment of femoro-acetabular impingement with surgical dislocation and debridement in young adults. Journal of Bone and Joint Surgery American 88, 1735-41.
Philippon, M.J., Briggs, K.K., Yen, Y.M. et al (2009). OUtcomes following hip arthroscopy for femoroacetabular impingement with associated chondrolabral dysfunction: minimum two-year follow-up. Journal of Bone and Joint Surgery British 91, 16-23.
Sampson, T.G. (2005). Arthroscopic treatment of femoroacetabular impingement. Techniques in Orthopaedics 20, 56-62.
This policy statement relates only to the services or supplies described herein. Coverage will vary from contract to contract and by line of business and should be verified before applying the terms of the policy.