Utilization Review Checklist
Glenohumeral Osteoarthrosis
Derived from the ACOEM Shoulder Disorders Guideline, edition 14 July 2025, as adopted into the California MTUS 2 January 2026. CPT 23472, 23470. ICD-10 M19.01.
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 shoulder glenohumeral joint pain
“● nonradiating shoulder glenohumeral joint pain,” — p. 278
AND
Functional impairment
“● functional impairment, and” — p. 278
AND
Reduced range of motion compared with the contralateral side, if unaffected
“● reduced range of motion (ROM) compared with the contralateral side (if unaffected). May include crepitus on ROM.” — p. 278
Confirmatory Diagnosis
Required
Imaging findings consistent with significant degenerative joint disease
“A confirmatory diagnosis of glenohumeral osteoarthrosis requires: ● Imaging findings consistent with significant degenerative joint disease.” — p. 278
Conservative Care
Required
Unresponsive or insufficiently responsive to both nonoperative treatments for a period of 6 months — at least 6 months
“● unresponsive or insufficiently responsive to both of the above nonoperative treatments for a period of 6 months” — p. 278
Procedures — the guideline treats each separately
Total shoulder arthroplasty for severe arthrosis
Moderately Recommended. Total shoulder arthroplasty is moderately recommended for highly selective patients with severe arthrosis.
Strength of Evidence — Moderately Recommended, Evidence (B) · confidence low · p. 278
Indications — all of the following:
Symptoms of glenohumeral osteoarthrosis for at least 6 months — at least 6 months
“● symptoms of glenohumeral osteoarthrosis for at least 6 months,” — p. 278
AND
Sufficient symptoms and functional limitations, such as impairments of activities of daily living and/or occupational tasks
“● sufficient symptoms and functional limitations, such as impairments of activities of daily living and/or occupational tasks,” — p. 278
AND
Significant glenohumeral degenerative joint disease on imaging
“● significant glenohumeral degenerative joint disease on imaging and” — p. 278
AND
Total shoulder arthroplasty requested
“Total shoulder arthroplasty is moderately recommended for highly selective patients with severe arthrosis.” — p. 278
Moderately Recommended on (B) evidence for highly selective patients. The guideline records that all three quality trials comparing total with hemiarthroplasty favour total or trend that way — worth citing if the choice of procedure is questioned.
Hemiarthroplasty for severe arthrosis
Moderately Recommended. Hemiarthroplasty is moderately recommended for highly selective patients with severe arthrosis.
Strength of Evidence — Moderately Recommended, Evidence (B) · confidence low · p. 280
Indications — all of the following:
Symptoms of glenohumeral osteoarthrosis for at least 6 months — at least 6 months
“● symptoms of glenohumeral osteoarthrosis for at least 6 months,” — p. 278
AND
Sufficient symptoms and functional limitations, such as impairments of activities of daily living and/or occupational tasks
“● sufficient symptoms and functional limitations, such as impairments of activities of daily living and/or occupational tasks,” — p. 278
AND
Significant glenohumeral degenerative joint disease on imaging
“● significant glenohumeral degenerative joint disease on imaging and” — p. 278
AND
Hemiarthroplasty requested
“Hemiarthroplasty is moderately recommended for highly selective patients with severe arthrosis.” — p. 280
Same grade and same criteria as total shoulder arthroplasty. Note the guideline's own evidence review favours total arthroplasty, so give your reason for choosing hemiarthroplasty.
Reverse shoulder arthroplasty for moderate to severe arthrosis
Moderately Recommended. Reverse shoulder arthroplasty is moderately recommended for highly selective patients with moderate to severe arthrosis.
Strength of Evidence — Moderately Recommended, Evidence (B) · confidence low · p. 281
Indications — all of the following:
Symptoms of glenohumeral osteoarthrosis for at least 6 months — at least 6 months
“● symptoms of glenohumeral osteoarthrosis for at least 6 months,” — p. 278
AND
Sufficient symptoms and functional limitations, such as impairments of activities of daily living and/or occupational tasks
“● sufficient symptoms and functional limitations, such as impairments of activities of daily living and/or occupational tasks,” — p. 278
AND
Significant glenohumeral degenerative joint disease on imaging
“● significant glenohumeral degenerative joint disease on imaging and” — p. 278
AND
Reverse shoulder arthroplasty requested
“Reverse shoulder arthroplasty is moderately recommended for highly selective patients with moderate to severe arthrosis.” — p. 281
The only one of the three the guideline extends to MODERATE as well as severe arthrosis. The stated surgical considerations are written for hemiarthroplasty and total arthroplasty; they are applied here as well, which is the stricter reading — see the flag.