Osteochondral Lesion of the Talus

Utilization Review Checklist

Derived from the ACOEM Ankle and Foot Disorders Guideline, edition 29 January 2026, as adopted into the California MTUS 1 August 2026. CPT 29892, 29891, 27625, 28446. ICD-10 M93.27, S92.1.

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.

Patient name: Claim #:

CriteriaCheck if documented

Confirmatory Diagnosis

Required

Confirmatory diagnostic evidence of an osteochondral lesion of the talus on x-ray, MRI and/or CT
“Confirmatory diagnostic evidence of an osteochondral lesion of the talus on x-ray, MRI and/or CT.” — p. 243

Surgical Considerations (microfracture or osteochondral autograft)

Required

Loose body, unstable or displaced lesion or osteochondral fracture; and/or failure to heal or improve after 6 weeks of non-weight-bearing and other nonoperative treatment
“Surgical considerations include either: 1) loose body or unstable or displaced lesion/defect or osteochondral fracture and/or 2) failure to heal or improve after 6 weeks of non-weight-bearing and other nonoperative treatment.” — p. 243
Any one of the following:
- Loose body or unstable or displaced lesion/defect or osteochondral fracture
  “1) loose body or unstable or displaced lesion/defect or osteochondral fracture” — p. 243
- OR
  Failure to heal or improve after 6 weeks of non-weight-bearing and other nonoperative treatment — at least 6 weeks
  “2) failure to heal or improve after 6 weeks of non-weight-bearing and other nonoperative treatment” — p. 243

Procedures — the guideline treats each separately

Operative intervention for an osteochondral lesion of the talus (microfracture or osteochondral autograft)

Recommended.

Strength of Evidence — Recommended, Insufficient Evidence (I) · confidence high

Confidence is High here, which is unusual for an Insufficient (I) evidence grade and works in the surgeon's favour. The guideline names microfracture and osteochondral autograft specifically. There are two alternative routes to surgery: an unstable or displaced lesion or loose body needs no waiting period, while a stable lesion requires six weeks of non-weight-bearing first.