Utilization Review Checklist
Acromioclavicular Joint Osteoarthrosis
Derived from the ACOEM Shoulder Disorders Guideline, edition 14 July 2025, as adopted into the California MTUS 2 January 2026. CPT 29824, 23120. ICD-10 M19.011, M19.012.
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
Presumptive Diagnosis
All of the following
Nonradiating AC joint pain
“● nonradiating AC joint pain and” — p. 276
AND
Tenderness aggravated by direct palpation
“● tenderness aggravated by direct palpation.” — p. 276
Confirmatory Diagnosis
All of the following
Degenerative findings on imaging studies
“● degenerative findings on imaging studies and” — p. 276
AND
Positive cross-arm adduction test
“● positive cross-arm adduction test and” — p. 276
AND
Diagnostic challenge test with lidocaine showing short-term resolution of pain
“● diagnostic challenge test with lidocaine showing short-term resolution of pain.” — p. 276
Conservative Care
All of the following
AC joint symptoms persisting for at least 6-12 months — at least 6 months
“● AC joint symptoms persisting for at least 6-12 months and” — p. 276
AND
Symptoms insufficiently managed by nonoperative means, including glucocorticosteroid injections
“● symptoms insufficiently managed by nonoperative means, including glucocorticosteroid injections.” — p. 276
Surgical Considerations (distal clavicle resection)
Required
Distal clavicle resection requested, arthroscopic or open
“There is no recommendation for or against distal clavicle resection (either arthroscopic or open) for treatment of acromioclavicular joint pain.” — p. 276
Procedures — the guideline treats each separately
Distal clavicle resection (Mumford procedure), arthroscopic or open
No Recommendation.
Strength of Evidence — No Recommendation, Insufficient Evidence (I) · confidence low
READ THIS BEFORE FILING. ACOEM gives NO RECOMMENDATION for or against distal clavicle resection — it neither supports the procedure nor advises against it, because there are no quality trials comparing clavicle excision with nonsurgical treatment. That is not the same as a denial: the guideline still publishes indications, and its Rationale says resection is potentially indicated for severe, chronic pain focused on the AC joint that nonoperative treatment has not sufficiently treated. Expect a reviewer to lean on the absent recommendation, and answer it by documenting all three confirmatory findings — especially the lidocaine challenge — and the full six to twelve months of symptoms.