Utilization Review Checklist
Shoulder Osteonecrosis (Avascular Necrosis)
Derived from the ACOEM Shoulder Disorders Guideline, edition 14 July 2025, as adopted into the California MTUS 2 January 2026. CPT 23470, 23472, 23000. ICD-10 M87.02.
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
Osteonecrosis of the humeral head, with the presence or absence of collapse stated
“Indications Patients with collapse of the humeral head are immediate candidates for arthroplasty.” — p. 305
Conservative Care
Required
Response or non-response to risk factor modification, or a judgement that delay is too risky
“Indications Patients with generally moderate to severe osteonecrosis either (i) not responding to risk factor modification and/or (ii) felt to be at risk of collapse and further delay while treating risk factors or treating with hyperbaric oxygen is felt to be too risky.” — p. 304
Procedures — the guideline treats each separately
Core decompression surgery
Recommended. Core decompression surgery is recommended to treat osteonecrosis.
Strength of Evidence — Recommended, Insufficient Evidence (I) · confidence low · p. 304
Indications — required:
Moderate to severe osteonecrosis without collapse
“Core decompression surgery is recommended to treat osteonecrosis.” — p. 304
The joint-preserving option, for moderate to severe osteonecrosis either not responding to risk factor modification OR at risk of collapse where further delay is too risky. It is an either/or. Once the humeral head has collapsed, arthroplasty is the better-supported route.
Arthroplasty for osteonecrosis with collapse or severe unresponsive disease
Recommended. Arthroplasty is recommended for treatment of osteonecrosis with collapse or severe disease unresponsive to non-operative treatment.
Strength of Evidence — Recommended, Insufficient Evidence (I) · confidence high · p. 305
Indications — required:
Collapse of the humeral head, or severe osteonecrosis unresponsive to risk factor modification or at significant risk of immediate collapse
“Indications Patients with collapse of the humeral head are immediate candidates for arthroplasty. Additional candidates include those with severe osteonecrosis who are: ● unresponsive to risk factor modification, and/or ● felt to be at significant risk of immediate collapse.” — p. 305
High confidence. The guideline says patients with COLLAPSE of the humeral head are IMMEDIATE candidates — no conservative requirement at all. Document the collapse and quote that word.