Utilization Review Checklist
Achilles Tendinopathy (without rupture)
Derived from the ACOEM Ankle and Foot Disorders Guideline, edition 29 January 2026, as adopted into the California MTUS 1 August 2026. CPT 27654, 27680. ICD-10 M76.6.
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
Moderate to severe chronic Achilles tendinopathy
“Indications Patients with moderate to severe chronic Achilles tendinopathies who have failed multiple non-surgical treatments and whose condition has lasted at least 6 months.” — p. 82
Conservative Care
All of the following
Condition lasting at least 6 months — at least 6 months
“whose condition has lasted at least 6 months.” — p. 82
AND
Failed multiple non-surgical treatments, generally including NSAIDs, eccentric exercises, iontophoresis, injections and low-level laser therapy
“Patients should generally have failed NSAID(s), eccentric exercises, iontophoresis, injection(s) and low level laser therapy.” — p. 82
Procedures — the guideline treats each separately
Surgery for chronic Achilles tendinopathy without rupture
Recommended. Surgery is recommended to treat select cases of chronic Achilles tendinopathy without rupture. There is no recommendation for any particular procedure over another.
Strength of Evidence — Recommended, Insufficient Evidence (I) · confidence low · p. 82
Indications — required:
Surgery for chronic Achilles tendinopathy requested
“Surgery is recommended to treat select cases of chronic Achilles tendinopathy without rupture. There is no recommendation for any particular procedure over another.” — p. 82
Six months of failed non-surgical treatment is the threshold, and the guideline names the treatments: NSAIDs, eccentric exercises, iontophoresis, injections and low-level laser therapy. It also states there is no recommendation for any particular procedure over another, so technique is not a ground for denial.
Surgery for acute or subacute Achilles tendinopathy without rupture
Not Recommended. Surgery is not recommended for the treatment of acute or subacute Achilles tendinopathy without rupture.
Strength of Evidence — Not Recommended, Insufficient Evidence (I) · confidence high · p. 82
Indications — required:
Surgery for acute or subacute Achilles tendinopathy requested
“Surgery is not recommended for the treatment of acute or subacute Achilles tendinopathy without rupture.” — p. 82
Not recommended at HIGH confidence. Do not file at this stage. Continue non-operative treatment to six months, document the named modalities, then request surgery for chronic tendinopathy.