Blue Cross NC Arthroscopic Hip Surgery for Impingement Syndrome Including Labral Repair prior authorization requirements (2026)

Medical-necessity criteria Blue Cross NC generally applies

Hip Arthroscopy - Femoroacetabular impingement syndrome (FAIS). Acetabuloplasty (pincer): "ALL the following criteria are required: Moderate to severe hip pain (primarily in the groin) worsened by flexion activities (e.g., squatting or prolonged sitting) that interferes with activities of daily living and is not explained by another diagnosis; Positive impingement sign on clinical examination, defined as pain elicited with 90 degrees of flexion and internal rotation and adduction of the femur OR with extension and external rotation; Imaging studies (radiographs, MRI, or 3D computed tomography) show pincer impingement as evidenced by ONE or more of the following: Lateral center-edge angle (CEA) of Wiberg >= 40 degrees; Coxa profunda or protrusion - acetabular fossa medial to ilioischial line; Posterior wall sign - cross-over sign; No evidence of advanced osteoarthritis, defined as Tonnis grade >= 2, or joint space < 2 mm; No evidence of severe (modified Outerbridge grade IV) chondral damage; Failure of conservative management for a duration of at least 12 weeks, including avoidance of hip stretching or any activity that elicits or aggravates symptoms (less than the full duration of conservative management is permitted for an alpha angle greater than 65 degrees); Documentation of a likely causal association between the femoroacetabular impingement morphology and damage to the acetabular margin or the femoral neck." Femoroplasty (cam): same pain, impingement sign, OA and chondral limits, and 12-week conservative-management requirements, with imaging showing "cam impingement evidenced by ONE or more of the following: Pistol-grip deformity; Femoral head-neck offset with an alpha angle greater than or equal to 55 degrees." Labral tear: "Hip arthroscopy is considered medically necessary for treatment of labral tear when ALL the following criteria are met: Moderate to severe hip pain (primarily in the groin) worsened by flexion activities (...); Positive impingement sign on clinical examination (...); MRI report that defines or suggests a labral tear; Failure of conservative management for a duration of at least 12 weeks, including avoidance of hip stretching or any activity that elicits or aggravates symptoms; No evidence of advanced osteoarthritis, defined as Tonnis grade >= 2, or joint space < 2 mm; No evidence of severe (modified Outerbridge grade IV) chondral damage." "Capsular plication, capsular repair, labral reconstruction, iliotibial band windowing, trochanteric bursectomy, abductor muscle repair, and/or iliopsoas tenotomy, when performed at the time of any FAIS surgery, would be considered a component of and incidental to the FAIS procedure." [NEEDS CLINICAL SPOT-CHECK]

Commonly required documentation

• Clinical notes with groin-pain description and flexion-activity aggravation, documented impingement sign, imaging report with CEA / alpha angle / cross-over sign and Tonnis grade and joint space, MRI describing the labrum, and a dated 12-week conservative-management record including activity avoidance. Documentation supporting medical necessity and a clearly stated plan of care should be submitted at the time of the request and must include the following components: Clinical notes describing symptom duration and severity, specific functional limitations related to symptoms, and type and duration of all therapeutic measures provided. If conservative management is not appropriate, the reason must be clearly documented. Conservative management must include a combination of strategies to reduce inflammation, alleviate pain, and correct underlying dysfunction, including physical therapy AND at least ONE complementary conservative treatment strategy (physical therapy rendered by a qualified provider, or a supervised home treatment program with initial active instruction by MD/DO/PT and documented compliance
• complementary = anti-inflammatory medications and analgesics, adjunctive medications, intra-articular corticosteroid injection(s), or activity modification / trial period of rest). Failure of conservative management requires ALL the following: Patient has completed a full course of conservative management (as defined above) for the current episode of care
• Worsening of or no significant improvement in signs and/or symptoms upon clinical reevaluation
• More invasive forms of therapy are being considered. Reporting symptom severity - significant pain and functional impairment refer to pain rated at least 3 out of 10 in intensity and associated with inability to perform ADLs and/or IADLs. Imaging reports obtained within the past 12 months describing the degree of cartilage damage: X-ray report or provider interpretation of x-rays that utilizes or can be correlated with the Kellgren-Lawrence grading system of osteoarthritis, and/or MRI report from a radiologist that utilizes or can be correlated with the modified Outerbridge or similar classification system. General Recommendations (strongly recommended, not required): tobacco/nicotine abstinence for at least 6 weeks prior to surgery
• hemoglobin A1C of 8% or less prior to any joint replacement surgery
• BMI equal to or greater than 40 attempt weight reduction prior to surgery.

Situations to verify before submitting

Blue Cross NC may not cover Arthroscopic Hip Surgery for Impingement Syndrome Including Labral Repair in these situations. Verify against the current policy rather than assuming a denial:

• {"text":"Exclusions: \"For hip debridement/chondroplasty: When performed for treatment of hip osteoarthritis (Kellgren-Lawrence grade >= 2, Tonnis grade >= 2). For treatment of FAIS/Labral repair: Use of capsular plication as the sole treatment of FAIS; Evidence of advanced osteoarthritis, defined as Tonnis grade >= 2, Kellgren-Lawrence grade 3 or 4, or joint space narrowing <= 2 mm along the lateral/medial sourcil; Evidence of severe (modified Outerbridge grade IV) chondral damage; Positive broken Shenton line; Inclination Tonnis angle greater than 10-15 degrees; Labral repair in the presence of untreated severe hip dysplasia.\"","source":"https://guidelines.carelonmedicalbenefitsmanagement.com/joint-surgery-2025-11-15/"}

How to submit

• Method: Prior authorization is delegated to Carelon Medical Benefits Management for spine surgery, joint surgery, interventional pain management, and small joint surgery (Commercial Fully Insured since 2023-10-01; ASO groups only if the group elected the program, effective 2025-01-01 - verify by member ID on the Carelon portal or via the number on the member ID card). Submit through the Carelon Provider Portal via Blue e (24/7, real-time against Carelon clinical guidelines) or by phone at 866-455-8414, Monday-Friday 8 a.m.-6 p.m. ET. Applies in both outpatient and inpatient admission settings. Since 2025-07-01 (Fully Insured only; excludes Medicare Advantage, DSNP, EGWP, FEP and ASO), a request for a hospital-based OUTPATIENT setting for interventional pain or joint-arthroscopy/small-joint procedures gets an additional site-of-care review.
• Portal: Carelon Provider Portal (via Blue e)
• Typical turnaround: about 3 days

Sources & verification

• BindingSource - Carelon Clinical Appropriateness Guidelines: Joint Surgery (Joint Surgery 2025-11-15) · effective 2025-11-15.View
• BindingSource - Blue Cross NC Musculoskeletal Program and Interventional Pain Management effective October 1, 2023 (Carelon delegation) (Provider news 2023-10-01) · effective 2023-10-01.View

Binding = the payer's own policy. Proxy = a public, evidence-based clinical guideline the payer mirrors. Portal-only = the binding criteria are confirmed in the administrator's portal. Always confirm against the payer for the member's specific plan. Last verified 2026-09-20.

Frequently asked questions

Other Blue Cross NC prior authorization requirements

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