Utilization Review Checklist
Achilles Tendon Rupture
Derived from the ACOEM Ankle and Foot Disorders Guideline, edition 29 January 2026, as adopted into the California MTUS 1 August 2026. CPT 27650, 27652, 27654. ICD-10 S86.01.
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
Any one of the following
Sudden pain in the posterior heel, often accompanied by a “pop”
“The cardinal symptom of an Achilles tendon rupture is a sudden pain in the posterior heel that is often accompanied by a “pop” heard emanating from the heel” — p. 83
OR
Loss of plantar flexion strength
“Diagnosis of an Achilles tendon rupture is most often based on loss of plantar flexion strength” — p. 83
OR
Palpation of a gap in the mid-portion of the tendon, proximal to the calcaneal insertion
“palpation of a gap in the mid-portion of the tendon (proximal to the calcaneal insertion)” — p. 83
OR
Positive squeeze test of the calf muscle that fails to elicit plantar flexion
“a positive squeeze test of the calf muscle that fails to elicit plantar flexion” — p. 83
OR
Resting dorsiflexion on the side of the rupture, or a positive Matles knee flexion test
“The examiner may encounter resting dorsiflexion on the side of the rupture. Other examination findings include the Matles knee flexion test” — p. 83
Confirmatory Diagnosis
All of the following
Rupture confirmed on history and physical examination
“A confirmed rupture of an Achilles tendon (based on history, physical examination, and imaging studies such as MRI and ultrasound) is the sole indication because repair is recommended in nearly all cases.” — p. 95
AND
Imaging studies such as MRI and ultrasound
“based on history, physical examination, and imaging studies such as MRI and ultrasound” — p. 95
Surgical Considerations (surgical repair)
Required
A confirmed rupture of an Achilles tendon is the sole indication
“A confirmed rupture of an Achilles tendon (based on history, physical examination, and imaging studies such as MRI and ultrasound) is the sole indication because repair is recommended in nearly all cases.” — p. 95
Procedures — the guideline treats each separately
Surgical repair of a ruptured Achilles tendon
Recommended.
Strength of Evidence — Recommended, Evidence (C) · confidence moderate
The guideline names a confirmed rupture as the SOLE indication and requires no trial of conservative care first. If a reviewer asks for a failed conservative course before authorising repair, that requirement is not in the adopted guideline — say so and cite this section. The guideline does ask that the equivocal benefit of surgery over non-operative care be discussed with the patient, so record that discussion.