MedicaidCoverageHigh impact
Surgery of the Hip (for Tennessee Only)
UnitedHealthcare·TN · Orthopedics, Sports Medicine·Medical Policy
Effective date
Oct 1, 2026
We identified it
Sep 2, 2026
Summary
UnitedHealthcare Community Plan of Tennessee revised its medical policy for hip surgery effective October 1, 2026. Key changes include: (1) removal of CPT code 29860 from covered procedures, (2) updated clinical criteria now requiring reference to InterQual® CP guidelines for medical necessity determination, and (3) new guidance stating that femoroacetabular impingement syndrome surgery is NOT medically necessary when advanced osteoarthritis (Tönnis grade 2-3) or severe cartilage damage (Outerbridge Grade III-IV) is present.
Action Required
By September 30, 2026: (1) Billing team must immediately remove CPT code 29860 from all hip surgery claim submissions for Tennessee Medicaid patients in billing system and ensure claims deny if this code is accidentally submitted. (2) Update all prior authorization workflows to require InterQual® CP: Procedures reference criteria for hip arthroscopy, surgical procedures, arthroplasty, and total joint replacement cases—claims cannot be submitted without documented InterQual® review. (3) Providers and clinical staff must document severity of osteoarthritis (Tönnis grade) and cartilage damage (Outerbridge grade) on ALL femoroacetabular impingement syndrome cases; if Tönnis grade 2-3 or Outerbridge Grade III-IV is present, claims will be denied as not medically necessary. (4) Update pre-operative screening checklists and encounter forms to capture these specific imaging findings. (5) Educate all hip surgery providers that the policy change limits coverage for impingement syndrome cases. Failure to comply will result in claim denials and potential rework.