Utilization Review Checklist
Chronic Lateral Ankle Instability
Derived from the ACOEM Ankle and Foot Disorders Guideline, edition 29 January 2026, as adopted into the California MTUS 1 August 2026. CPT 27698, 27695, 27696. ICD-10 M25.37, S93.4.
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.
Procedures — the guideline treats each separately
Ligament reconstruction for chronic ankle instability
Recommended. Ligament reconstruction is recommended for select cases of chronic ankle instability.
Strength of Evidence — Recommended, Insufficient Evidence (I) · confidence moderate · p. 193
Indications — required:
Ligament reconstruction requested for a select case of chronic ankle instability
“Ligament reconstruction is recommended for select cases of chronic ankle instability.” — p. 193
The guideline heads this recommendation "Sometimes Recommended" and grades the evidence Insufficient (I), so expect the criteria to be read strictly. All three of the four-month duration, the failed exercise programme and the failed brace must be documented, and the instability must be confirmed on MRI or stress x-rays.
Surgical repair of an acute or subacute lateral ligament tear
Not Recommended. Surgical repair is not recommended for routine lateral ligament tear associated with acute or subacute ankle sprain.
Strength of Evidence — Not Recommended, Insufficient Evidence (I) · confidence low · p. 192
Indications — required:
Surgical repair requested for a routine lateral ligament tear associated with acute or subacute ankle sprain
“Surgical repair is not recommended for routine lateral ligament tear associated with acute or subacute ankle sprain.” — p. 192
The guideline does NOT recommend surgical repair for a routine lateral ligament tear from an acute or subacute ankle sprain. A request will very likely be denied however well the note is written, and no amount of documentation changes the recommendation. If the ankle remains unstable, the supported route is to treat non-operatively, document the failure of exercises and bracing, and request reconstruction once the instability has persisted four months.