Carelon Arthroscopic Hip Surgery for Impingement Syndrome Including Labral Repair prior authorization requirements (2026)
What Carelon generally requires to approve Arthroscopic Hip Surgery for Impingement Syndrome Including Labral Repair (CPT 29914, 29915, 29916, 29860, 29861, 29862, 29863), for Commercial plans. Yes. Carelon generally requires prior authorization for Arthroscopic Hip Surgery for Impingement Syndrome Including Labral Repair (CPT 29914, 29915, 29916, 29860, 29861, 29862, 29863).
Medical-necessity criteria Carelon generally applies
Patient must meet ALL: (1) MRI or MR arthrogram confirming FAI morphology (cam deformity: alpha angle >55°, pincer deformity: lateral CE angle >40°) with or without associated labral tear or chondral damage; (2) Clinical presentation: groin or anterior hip pain, positive FADIR and/or FABER test, limited internal rotation on exam, symptoms ≥3 months; (3) Failure of ≥3 months structured PT (≥8 sessions specifically targeting hip external rotators, abductors, and core stabilizers) plus NSAID trial; (4) Absence of significant hip arthritis: Tönnis Grade 0–1 OR K-L Grade ≤1 (Grade 2 with focal cartilage loss may be considered case-by-case); (5) HOS (Hip Outcome Score) or iHOT-33 documenting severe functional limitation
Commonly required documentation
- MRI or MR arthrogram with alpha angle and CE angle measurements in radiologist report
- documented physical exam (FADIR, FABER, Trendelenburg, ROM with internal rotation measured)
- hip-specific PT records (≥8 sessions)
- HOS ADL or iHOT-33 score
- standing AP pelvis X-ray and lateral hip X-ray with alpha angle
- surgeon evaluation confirming FAI and ruling out advanced arthritis
How to submit
- Portal: Carelon Provider Portal
- Typical turnaround: about 3 days
Source
HOS or iHOT-33 score is Carelon-specific — document before submitting. Cases with K-L Grade 2 arthritis are often denied and require peer-to-peer. Alpha angle must be explicitly measured and reported — do not assume radiologist will include it without requesting.
Frequently asked questions
Does Carelon require prior authorization for Arthroscopic Hip Surgery for Impingement Syndrome Including Labral Repair?
Yes. Carelon generally requires prior authorization for Arthroscopic Hip Surgery for Impingement Syndrome Including Labral Repair (CPT 29914, 29915, 29916, 29860, 29861, 29862, 29863).
What does Carelon require to approve Arthroscopic Hip Surgery for Impingement Syndrome Including Labral Repair?
Patient must meet ALL: (1) MRI or MR arthrogram confirming FAI morphology (cam deformity: alpha angle >55°, pincer deformity: lateral CE angle >40°) with or without associated labral tear or chondral damage; (2) Clinical presentation: groin or anterior hip pain, positive FADIR and/or FABER test, limited internal rotation on exam, symptoms ≥3 months; (3) Failure of ≥3 months structured PT (≥8 sessi… Always confirm against the current Carelon policy.
How long does a Carelon prior authorization take?
Carelon typically decides Arthroscopic Hip Surgery for Impingement Syndrome Including Labral Repair requests in about 3 days. Timeframes vary; check the payer portal.
Submitting Arthroscopic Hip Surgery for Impingement Syndrome Including Labral Repair to Carelon?
Praxigen checks your clinical note against these criteria before you submit and drafts a policy-cited appeal if it is denied. You review and submit; nothing is sent automatically.