Utilization Review Checklist
Medial Collateral Ligament Tear
Derived from the ACOEM Knee Disorders Guideline, edition 3 December 2019, as adopted into the California MTUS 21 September 2020. CPT 27405, 27409. ICD-10 S83.41.
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
Isolated Grade III medial collateral ligament tear
“Surgery in isolated Grade III MCL tears is usually not necessary because of the documented excellent healing potential of this ligament with closed (i.e., non-operative) treatment.” — p. 133
Conservative Care
Required
Failure of non-operative management
“Surgery is only recommended in those rare select cases of failure of non-operative management.” — p. 133
Surgical Considerations (MCL repair or reconstruction)
Required
Surgery requested for a rare select case of failed non-operative management
“Surgery is only recommended in those rare select cases of failure of non-operative management.” — p. 133
Procedures — the guideline treats each separately
Surgery for an isolated Grade III MCL tear
Recommended.
Strength of Evidence — Recommended, Insufficient Evidence (I)
Set expectations before filing. The guideline says surgery in isolated Grade III MCL tears is USUALLY NOT NECESSARY because this ligament has documented excellent healing potential with closed treatment, and recommends it only in 'those rare select cases of failure of non-operative management'. So the whole case rests on documenting a completed non-operative course and its failure — not on the grade of the tear.