All PlansPrior AuthMedium impact
Femoroacetabular Impingement Surgery
Regence BlueShield·Orthopedics, Sports Medicine·Medical Policy
Effective date
Oct 1, 2026
We identified it
Jul 7, 2026
Summary
This is a new medical policy (effective October 1, 2026) establishing coverage criteria for femoroacetabular impingement (FAI) surgery. The policy requires patients to meet strict criteria including skeletally mature status, moderate-to-severe hip pain unresponsive to 3+ months of conservative therapy, positive clinical impingement signs, imaging confirmation of FAI morphology, and absence of contraindications (advanced osteoarthritis, joint space <2mm, severe femoral retroversion/anteversion, broken Shenton line, or Tonnis angle >13-15 degrees). Billing teams must prepare authorization workflows and documentation requirements before October 1, 2026.
Action Required
Before October 1, 2026: (1) Billing team must establish prior authorization workflow requiring submission of History & Physical, documented conservative treatment attempts (minimum 3 months), physical exam findings, and imaging (x-rays, MRI, or MRI arthrogram) showing cam-type or pincer-type FAI morphology. (2) Update billing system to flag FAI surgery claims for pre-service review against six mandatory criteria (skeletally mature, pain severity, conservative therapy failure, positive impingement sign, imaging confirmation, absence of contraindications). (3) Providers must document clinical findings (90-degree flexion with internal rotation/adduction causing pain) and imaging parameters (alpha angle, pistol-grip deformity, wall sign, acetabular retroversion, coxa profunda, rim damage). (4) Claims missing any required documentation will be denied; providers should be notified to obtain missing items before claim submission. (5) Create internal checklist identifying exclusionary findings (Tonnis grade II/III osteoarthritis, joint space <2mm except with mechanical instability, Tonnis angle >13-15 degrees, broken Shenton line, severe femoral retroversion/anteversion with gait abnormality) that automatically trigger denial. (6) Note that adjunctive procedures (capsular plication/repair, chondroplasty, microfracture, labral reconstruction, IT band windowing, bursectomy, muscle repair, subspine decompression, iliopsoas tenotomy) are considered component/incidental to FAI procedure and should not be billed separately.