Utilization Review Checklist
Femoroacetabular Impingement, “Hip Impingement,” and Labral Tears
Derived from the ACOEM Hip and Groin Disorders Guideline, edition 29 January 2026, as adopted into the California MTUS 1 August 2026. CPT 29914, 29915, 29916. ICD-10 M25.85, M24.85, S73.19, M24.15.
Draft — not reviewed or approved by COA. Prepared by Rette from the ACOEM guideline named above. This is not a COA document and does not reproduce COA’s own checklists.
CriteriaCheck if documented
Presumptive Diagnosis
At least 3 of the following
Nonradiating hip pain with range of motion
“1) nonradiating hip pain with range of motion” — p. 254
OR
Provocation with specific, predictable activities, such as specific positions
“2) provocation with specific, predictable activities, such as specific positions (e.g., pain with hip flexion)” — p. 254
OR
Buckling, clicking or catching
“3) buckling, clicking or catching” — p. 254
OR
Hip pain that is worse with pivoting and walking
“4) hip pain that is worse with pivoting and walking” — p. 254
Conservative Care
All of the following
Oral nonopioid analgesics and activity modification attempted
“failure to successfully manage symptoms after oral nonopioid analgesics and activity modification for a minimum of 3 months” — p. 254
AND
Failure to successfully manage symptoms for a minimum of 3 months — at least 3 months
“failure to successfully manage symptoms after oral nonopioid analgesics and activity modification for a minimum of 3 months” — p. 254
Procedures — the guideline treats each separately
Hip arthroscopy for femoroacetabular impingement or labral tear
Recommended.
Strength of Evidence — Recommended, Insufficient Evidence (I) · confidence moderate
Confirmatory Diagnosis
Any one of the following
Impingement: confirmatory findings on x-ray without moderate or severe hip arthritis
“Should have confirmatory findings on x-ray without moderate or severe hip arthritis.” — p. 254
OR
Labral tear: confirmatory findings on MRI, MRA, or ultrasound, plus x-rays that do not show moderate or severe hip arthritis
“Should have confirmatory findings on MRI, MRA, or ultrasound, plus x-rays that do not show moderate or severe hip arthritis.” — p. 254
Surgical Considerations (one procedure path)
Any one of the following
Hip arthroscopy for femoroacetabular impingement or labral tear
“Arthroscopy is recommended to diagnose and treat patients with hip pain if there is a suspicion of labral tear, intraarticular body, femoroacetabular impingement, or there are other subacute or chronic mechanical symptoms.” — p. 254
Required:
Sufficient symptoms and functional limitations that may include impairments of activities of daily living or occupational tasks
“1) sufficient symptoms and functional limitations that may include impairments of activities of daily living or occupational tasks” — p. 254
The guideline recommends arthroscopy for these diagnoses, but the evidence grade is Insufficient (I). Expect the reviewer to read the conservative-care duration closely, because that is the criterion the guideline states numerically.
Open surgical repair for hip impingement or labral tear
Recommended. Open surgical repair is recommended for hip impingement or labral tear cases that fail conservative management and either fail arthroscopic repair and/or are thought to be best treated with an open approach.
Strength of Evidence — Recommended, Insufficient Evidence (I) · confidence moderate · p. 256
Indications — all of the following:
Sufficient symptoms and functional limitations that may include impairments of activities of daily living or occupational tasks
“1) sufficient symptoms and functional limitations that may include impairments of activities of daily living or occupational tasks” — p. 254
AND
Failed arthroscopic repair and/or thought to be best treated with an open approach
“Generally, should either have failed arthroscopic repair and/or thought to be best treated with an open approach.” — p. 256
The guideline supports an open approach only for cases that fail conservative management AND either failed arthroscopic repair or are thought to be best treated open. State which of those two applies.