Anterior Cruciate Ligament Tear

Utilization Review Checklist

Derived from the ACOEM Knee Disorders Guideline, edition 3 December 2019, as adopted into the California MTUS 21 September 2020. CPT 29888. ICD-10 S83.5.

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

Conservative Care

Required

Attempted non-operative treatment including progressive exercise implemented after the acute phase of swelling has subsided
“Indications – Patients should generally have attempted non-operative treatment that included progressive exercise implemented after the acute phase of swelling, if any, has subsided.” — p. 140

Surgical Considerations (ACL reconstruction)

All of the following

Select patient, including those with high demand jobs or high performance athletes who more frequently fail non-operative rehabilitation
“Some patients, particularly those with high demand jobs or high performance athletes, may be candidates for early surgical reconstruction, as they are believed to more frequently fail non-operative rehabilitation.” — p. 140
AND
Surgical reconstruction requested for a confirmed ACL tear
“Surgical reconstruction of ACL tears is sometimes recommended for treatment of select patients with ACL tears.” — p. 140

Procedures — the guideline treats each separately

Surgical reconstruction of an ACL tear

Recommended.

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

The guideline explicitly says there is NO rush to operate and that moderate-quality evidence shows delay does not impair outcomes — so a reviewer proposing further rehabilitation first is on solid ground, and the request should meet that head-on. Two things help: that non-operative treatment including progressive exercise was attempted after the acute swelling subsided, and that this patient is one of those the guideline names as candidates for EARLY reconstruction — high demand jobs or high performance athletes, who it says more frequently fail non-operative rehabilitation.