Utilization Review Checklist
Gluteus Medius Tear (Greater Trochanteric Pain Syndrome)
Derived from the ACOEM Hip and Groin Disorders Guideline, edition 29 January 2026, as adopted into the California MTUS 1 August 2026. CPT 27036, 27006. ICD-10 M76.0, M70.6.
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
Tear of the gluteus medius tendon with accompanying pain and/or functional deficits
“Indications Tears of the gluteus medius tendon with accompanying pain and/or functional deficits felt amenable to surgical treatment.” — p. 263
Conservative Care
Required
Generally at least 3 weeks of non-operative treatment — at least 3 weeks
“Generally at least 3 weeks of non-operative treatment is advisable to ascertain whether the pain and/or function will sufficiently recover without need for surgery.” — p. 263
Surgical Considerations (surgical repair)
Required
Tear felt amenable to surgical treatment and non-responsive to medical management
“Surgical repair is recommended for gluteus medius tears that are non-responsive to medical management.” — p. 263
Procedures — the guideline treats each separately
Surgical repair for gluteus medius tears
Recommended.
Strength of Evidence — Recommended, Insufficient Evidence (I) · confidence moderate
The conservative threshold here is only THREE WEEKS, and even that is worded as 'generally advisable' rather than required. That is among the shortest in any of these chapters — a request held back for months of therapy is being judged against a standard the guideline does not set.