Utilization Review Checklist
Olecranon Bursitis
Derived from the ACOEM Elbow Disorders Guideline, edition 14 July 2025, as adopted into the California MTUS 2 January 2026. CPT 24105, 20605. ICD-10 M70.2, M70.3.
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
Conservative Care
Any one of the following
Infected, or clinically thought to be infected
“Olecranon bursitis that is either infected, clinically thought to be infected,” — p. 136
OR
Not infected but present at least approximately 6 to 8 weeks without trending towards resolution, while treated with soft padding and activity modification — at least 6 weeks
“or not infected but present for at least approximately 6 to 8 weeks without trending towards resolution while being treated with soft padding and activity modifications above.” — p. 136
Procedures — the guideline treats each separately
Surgical drainage for olecranon bursitis
Recommended. Surgical drainage is recommended for treatment of olecranon bursitis.
Strength of Evidence — Recommended, Insufficient Evidence (I) · p. 136
Indications — required:
Drainage requested
“Surgical drainage is recommended for treatment of olecranon bursitis.” — p. 136
Two routes, and they are very different in urgency. An INFECTED bursa — or one clinically thought to be infected — needs no waiting period at all. A non-infected bursa needs roughly 6 to 8 weeks without trending towards resolution, while being treated with soft padding and activity modification. Say which applies.
Surgical resection of the bursa for chronic olecranon bursitis
Recommended. Surgical resection of the bursa is recommended for chronic olecranon bursitis with recurrent drainage.
Strength of Evidence — Recommended, Insufficient Evidence (I) · p. 136
Indications — required:
Chronic olecranon bursitis with recurrent drainage
“Surgical resection of the bursa is recommended for chronic olecranon bursitis with recurrent drainage.” — p. 136
Resection is recommended for CHRONIC bursitis WITH RECURRENT DRAINAGE. Both words carry the request — document the chronicity and the recurrent drainage episodes with dates.