Utilization Review Checklist
Elbow Osteoarthrosis
Derived from the ACOEM Elbow Disorders Guideline, edition 14 July 2025, as adopted into the California MTUS 2 January 2026. CPT 29830, 29834, 29837. ICD-10 M19.02.
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
Confirmatory Diagnosis
Required
Presence or absence of a remediable mechanical defect such as a symptomatic loose body
“Arthroscopy is not recommended for treatment in acute, subacute, or chronic patients with osteoarthrosis in the absence of a remediable mechanical defect such as symptomatic loose body.” — p. 53
Procedures — the guideline treats each separately
Elbow arthroscopy for diagnosis of osteoarthrosis
Not Recommended. Arthroscopy is not recommended for diagnosis for patients with acute, subacute, or chronic osteoarthrosis in the absence of a remediable mechanical defect such as symptomatic loose body.
Strength of Evidence — Not Recommended, Insufficient Evidence (I) · p. 52
Indications — required:
Elbow arthroscopy for diagnosis of osteoarthrosis requested
“Arthroscopy is not recommended for diagnosis for patients with acute, subacute, or chronic osteoarthrosis in the absence of a remediable mechanical defect such as symptomatic loose body.” — p. 52
Not recommended in the ABSENCE of a remediable mechanical defect such as a symptomatic loose body. That qualifier is the whole of it: if imaging shows a loose body or another remediable mechanical defect, the sentence the guideline uses to decline arthroscopy no longer describes your patient. Document the defect.
Elbow arthroscopy for treatment of osteoarthrosis
Not Recommended. Arthroscopy is not recommended for treatment in acute, subacute, or chronic patients with osteoarthrosis in the absence of a remediable mechanical defect such as symptomatic loose body.
Strength of Evidence — Not Recommended, Insufficient Evidence (I) · p. 53
Indications — required:
Elbow arthroscopy for treatment of osteoarthrosis requested
“Arthroscopy is not recommended for treatment in acute, subacute, or chronic patients with osteoarthrosis in the absence of a remediable mechanical defect such as symptomatic loose body.” — p. 53
Not recommended in the absence of a remediable mechanical defect such as a symptomatic loose body. Same qualifier as the diagnostic recommendation — a documented loose body changes which sentence applies to the request.
Elbow arthroscopy with chondroplasty for osteoarthrosis
Not Recommended. Arthroscopy with chondroplasty is not recommended for treatment of osteoarthrosis.
Strength of Evidence — Not Recommended, Insufficient Evidence (I) · p. 54
Indications — required:
Elbow arthroscopy with chondroplasty for osteoarthrosis requested
“Arthroscopy with chondroplasty is not recommended for treatment of osteoarthrosis.” — p. 54
Not recommended, and unlike the other two this one carries NO 'absence of a remediable defect' qualifier — the guideline declines chondroplasty for osteoarthrosis outright. Compare the knee chapter, where chondroplasty and debridement for knee osteoarthrosis is Moderately Not Recommended on (B) evidence from a sham-controlled trial.