United Healthcare's new FAI Ruling

It has been brought to my attention that UHC has made a ridiculous ruling, basically trying to screw us all out of getting our symptomatic hips fixed and allowing us to return to a normal life. I am currently compiling information to prove that their ruling is wrong, unfair, and based on a small number of articles which state that further research needs to be conducted in FAI. they neglected to include the other articles which show that FAI surgery is successful. Below is their take on the issue. Please feel free to write, call, email etc the people at UHC and voice your opinion. If you would like the names of specific people to email (i.e VP and president of HR, medical director), please email me, or leave your email in the "comments" section of this post.


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Femoroacetabular Impingement Syndrome
Type
Technology Assessment
Number
2009T0530A

Approved By
Approval Date
Medical Technology Assessment Committee
8/20/2009

Description
After evaluating relevant benefit document language (exclusions or limitations), refer to Coverage sections of this document to determine coverage.
This policy describes surgical treatment for femoroacetabular impingement (FAI).
Coverage
All reviewers must first identify member eligibility, any federal or state regulatory requirements and the plan benefit coverage prior to use of this policy.
Coverage RationaleSurgical treatment, both arthroscopic and open, for femoroacetabular impingement (FAI) syndrome is unproven. This includes the arthroscopic or open procedure itself, removal of any bony and soft tissue pathology including resection of excessive acetabular bone coverage, resection of femoral head-neck junction, labral repair with or without grafting, and debridement or shaving of articular cartilage. At the present time, there is insufficient evidence of long-term efficacy and safety. Long-term, randomized controlled trials are needed to help clinicians better understand the diagnosis and make effective recommendations for treatment.Centers for Medicare and Medicaid Services (CMS): Medicare does not have a national coverage policy for femoroacetabular impingement surgery. Local Coverage Determinations (LCDs) does not exist at this time. Accessed May 11, 2009.
Regulatory Requirements
U.S. Food and Drug Administration (FDA): Although arthroscopic hip surgery for FAI is a procedure that is not subject to FDA regulation, devices and instruments used during the surgery require FDA approval. A search of the FDA 510(k) database revealed over 500 arthroscopes approved for marketing (product code HRX); however, the available studies did not provide sufficient information to determine which 510(k) approvals correspond to the instruments used.Additional information is available at: http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMN/pmn.cfm Accessed August 3, 2009.
Research Evidence
BackgroundFemoroacetabular impingement (FAI), formerly called acetabular rim syndrome or cervicoacatebular impingement, is the main cause of early damage to the acetabular labrum and articular cartilage of the hip, particularly in young, active patients and high-level athletes. In patients with FAI, limitation of both flexion and internal rotation occur at the hip joint as a result of premature pathologic contact between the skeletal prominences of the acetabulum and the femur. FAI generally occurs in one joint; however, in rare cases both hips can be involved. Surgical treatment has been utilized to improve the clearance for motion at the hip joint and lessen the femoral thrust against the acetabular rim. If left untreated, FAI may lead to osteoarthrosis of the hip. (ECRI, 2008)FAI is common in patients presenting with low back pain, cartilage damage, hip pain, loss of range of motion, disability, and sport hernias. Most patients can be diagnosed with a good history, physical examination, plain x-ray, and magnetic resonance imaging. The three types of FAI include the following (ECRI, 2008; NHS 2007): 1) cam impingement due to an aspherical portion of the femoral head-neck junction (i.e., femoral cause) which is most common in young athletes;2) pincer impingement due to focal or wide-ranging excessive coverage of the ball or femoral head (i.e., acetabular cause) which is most common in athletic, middle-aged women; 3) mixed pincer and cam impingement which is the most common type of FAI. Clinical EvidenceA systematic review by Bedi et al. (2008) reviewed 19 articles to determine the quality of the literature assessing outcomes after surgical treatment of labral tears and femoroacetabular impingement (FAI), patient satisfaction after open or arthroscopic intervention, and differences in outcome with open or arthroscopic approaches. The studies reviewed support that 65% to 85% of patients are satisfied with their outcome at a mean of 40 months after surgery. A common finding in all series, however, was an increased incidence of failure among patients with substantial pre-existing osteoarthritis. Arthroscopic treatment of labral tears is also effective, with 67% to 100% of patients being satisfied with their outcomes. The authors concluded that the quality of literature reporting outcomes of surgical intervention for labral tears and FAI is limited. Although open surgical dislocation with osteoplasty is the historical gold standard, the scientific data does not show that open techniques have outcomes superior to arthroscopic techniques.In a prospective observational study, Tanzer and Noiseux (2004) examined the role of FAI in hip disorders. For this study, 38 patients who had labral tears detected during hip arthroscopy and who had radiographic evidence of FAI were followed prospectively after arthroscopic removal of the torn portion of the labrum. Labral tear development was acute as evidenced by a twisting episode or well-defined precipitating event for 19 (50%) patients, insidious or gradual onset of worsening symptoms for 12 (32%), and due to major trauma as evidenced by a violent impact or dislocation for 7 (18%). In 16 (43%) of these patients, arthritic changes were identified on radiographs taken after arthroscopy. Damage associated with acetabular tears included femoral or global arthritic changes in 7 (18%) patients, anterior acetabular arthritic changes in 6 (16%), and femoral chondral lesions in 3 (8%). At 1 year of follow-up of 24 (63%) patients, mechanical symptoms had resolved completely in all patients; however, only 6 (25%) of these patients no longer had pain. The authors concluded that although arthroscopy for hip impingement is promising, future studies are needed to determine if correction of the anterior hip impingement, early in the natural history of the disease, may delay or prevent end-stage arthritis. This study is limited by small sample size with short term follow-up and a non controlled study design.In a prospective study by Peters and Erickson (2006), 30 hips (29 patients) with femoro-acetabular impingement underwent debridement through a greater trochanteric flip osteotomy and anterior dislocation of the femoral head. Cam (femoral based) impingement was noted in 14 hips; pincer (acetabular based) impingement in 1hip; and combined cam and pincer impingement in 15 hips. Mean patient age was 31 years. The mean duration of clinical and radiographic follow-up was 32 months. All patients were followed according to a prospective protocol, with Harris hip scores and plain radiographs obtained preoperatively and at 6 months, 1 year, and annually for a minimum of 2 years. The mean Harris hip score improved from 70 points preoperatively to 87 points at the time of final follow-up. In 18 hips, severe damage of the acetabular articular cartilage that had not been appreciated on preoperative plain radiographs or magnetic resonance arthrography was noted on arthrotomy. Eight of these 18 hips subsequently had radiographic evidence of progression of the osteoarthritis, and 4 of the 8 hips required or were expected to soon require conversion to a total hip arthroplasty to treat progressive pain. The authors concluded that surgical dislocation and debridement of the hip for the treatment of femoro-acetabular impingement in hips without substantial damage to the articular cartilage can reduce pain and improve function. This study is limited by its uncontrolled study design and small sample size.Sampson (2005) conducted a retrospective study of arthroscopic hip surgery for FAI, which reported results for 156 patients, some of whom underwent bilateral arthroscopic surgery. The ages of these patients ranged from 14 to 75 years, and most were between the ages of 20 and 40 years. Symptoms were generally mild and included somewhat reduced range of motion (ROM), poor tolerance of prolonged sitting, and inability to participate in sports. For the majority of patients, pain relief was 50% in 6 to 12 weeks, 75% in 5 months, and 95% in 1 year. Patients no longer needed crutches after 2 to 4 weeks. After follow-up ranging up to 22 months, 3 (2%) patients opted for total joint replacement due to continued pain. The average follow-up period and protocol for follow-up were not reported. This study is limited by its retrospective design, heterogenous patient population which limits the generalization of this data to other populations or who is best suited for the procedure, and lack of defined follow-up period and protocols.An uncontrolled study by Larson and Giveans ( 2008) on 96 patients (100 hips), was conducted to evaluate the early outcomes of arthroscopic management of femoroacetabular impingement (FAI). There were 54 male and 42 female patients with a mean age was 34.7 years. The surgical procedures performed were 26 (26%) proximal femoral osteoplasties, 21 (21%) acetabular rim trimmings, and 53 (53%) combination osteoplasties and trimmings. Patients also underwent labral debridement and repair or refixation as needed. At a mean of 10 months follow-up compared with baseline, mean pain score decreased from 6.7 to 1.9, mean Harris Hip score increased from 61 to 83, and mean SF-12 quality-of-life score increased from 60 to 78. All of these improvements were statistically significant (P<0.001). n="19" name="
References and Resources
ResourcesAmerican College of Rheumatology (ACR) [website]. Recommendations for the Medical Management of Osteoarthritis of the Hip and Knee. American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Arthritis Rheum. 2000;43(9):1905-1915. Available at: http://www.rheumatology.org/publications/guidelines/oa-mgmt/oa-mgmt.asp?aud=mem Accessed June 1, 2009.Bedi A, Chen N, Robertson W, Kelly BT. The management of labral tears and femoroacetabular impingement of the hip in the young, active patient. Arthroscopy. 2008 Oct;24(10):1135-45.ECRI Institute. Hotline Response. Surgical Treatment of Femoroacetabular Impingement. June 2008.Hayes, Inc. Health Technology Brief. Arthroscopic Hip Surgery for Femoroacetabular Impingement (FAI). Lansdale, PA: Hayes, Inc.; July 18, 2008.Ilizaliturri VM Jr, Orozco-Rodriguez L, Acosta-RodrE, Camacho-Galindo J. Arthroscopic treatment of cam-type femoroacetabular impingement: preliminary report at 2 years minimum follow-up. J Arthroplasty. 2008;23(2):226-234.Larson CM, Giveans MR. Arthroscopic management of femoroacetabular impingement: early outcomes measures. Arthroscopy. 2008;24(5):540-546.National Institute for Health and Clinical Excellence (NICE). Open femoro-acetabular surgery for hip impingement syndrome. Interventional Procedure Guidance 203. London, UK: NICE; January 2007a. Available at: http://www.nice.org.uk/nicemedia/pdf/IPG203guidance.pdf Accessed May 1, 2009.National Institute for Health and Clinical Excellence (NICE). Arthroscopic femoro-acetabular surgery for hip impingement syndrome. Interventional Procedure Guidance 213. London, UK: NICE; March 2007b. Available at: http://www.nice.org.uk/nicemedia/pdf/ip/IPG213Guidance.pdf Accessed May 1, 2009. National Library for Health (NLH). NHS Evidence. Surgery for Femoroacetabular Impingement. 2007. Available at: http://www.library.nhs.uk/trauma_orthopaedics/viewResource.aspx?resID=269337 Accessed June 1, 2009.Peters CL, Erickson JA. Treatment of femoro-acetabular impingement with surgical dislocation and din young adults. J Bone Joint Surg Am. 2006 Aug;88(8):1735-41. Philippon MJ, Yen YM, Briggs KK, Kuppersmith DA, Maxwell RB. Early outcomes after hip arthroscopy for femoroacetabular impingement in the athletic adolescent patient: a preliminary report. J Pediatr Orthop. 2008 Oct-Nov;28(7):705-10.Philippon MJ, Stubbs AJ, Schenker ML, Maxwell RB, et al. Arthroscopic Management of femoroacetabular impingement; Osteoplasty technique and literature review. Am J Sports Med. 2007; 35(9):1571-1580.Sampson TG. Arthroscopic treatment of femoroacetabular impingement. Tech Orthop. 2005;20(1):56-62.Stahelin L, Stahelin T, Jolles BM, Herzog RF. Arthroscopic offset restoration in femoroacetabular cam impingement: accuracy and early clinical outcome. Arthroscopy. 2008;24(1):51-57.Tanzer M, Noiseux N. Osseous abnormalities and early osteoarthritis: the role of hip impingement. Clin Orthop Relat Res. 2004;(429):170-177.
History/Updates
9/1/2009
New Policy.
Coding

The Current Procedural Terminology (CPT) codes and HCPCS codes listed in this policy are for reference purposes only. Listing of a service code in this policy does not imply that the service described by this code is a covered or non-covered health service. Coverage is determined by the benefit document.CPT Codes:
27299
Unlisted procedure, pelvis or hip joint
29999
Unlisted procedure, arthroscopy