Utilization Review Checklist
Hip Osteoarthrosis
Derived from the ACOEM Hip and Groin Disorders Guideline, edition 29 January 2026, as adopted into the California MTUS 1 August 2026. CPT 27130. ICD-10 M16.
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
Non-radiating hip pain
“● Non-radiating hip pain” — p. 54
AND
Morning stiffness or stiffness on standing after prolonged sitting
“● Morning stiffness or stiffness on standing after prolonged sitting” — p. 54
AND
Range of motion generally reduced, especially hip internal rotation
“● Range of motion (ROM) generally reduced, especially hip internal rotation” — p. 54
Confirmatory Diagnosis
Required
Radiographs (x-rays) obtained to assist in diagnosing hip osteoarthrosis
“Radiographs (x-rays) are recommended to assist in diagnosing hip osteoarthrosis.” — p. 71
Conservative Care
Required
Failure to successfully manage symptoms after a prolonged period of a conservative management plan that included NSAIDs, exercise, physical or occupational therapy, and where appropriate, weight reduction
“3) failure to successfully manage symptoms after a prolonged period of a conservative management plan that included NSAIDs, exercise, physical or occupational therapy, and where appropriate, weight reduction” — p. 158
Surgical Considerations (hip arthroplasty)
All of the following
Severe hip degenerative joint disease, osteonecrosis with collapse or unresponsive to non-operative treatment, or hip dysplasia
“All of the following present: 1) severe hip degenerative joint disease, osteonecrosis with collapse or unresponsive to non-operative treatment, or hip dysplasia (x-rays may indicate moderately severe, but function may be severely impaired);” — p. 157
AND
Sufficient symptoms and functional limitations such as impairments of activities of daily living or occupational tasks
“functional limitations such as impairments of activities of daily living or occupational tasks” — p. 158
Procedures — the guideline treats each separately
Hip arthroplasty for severe hip osteoarthrosis, osteonecrosis, or dysplasia
Strongly Recommended.
Strength of Evidence — Strongly Recommended, Evidence (A) · confidence high
This is the strongest grade ACOEM gives — Strongly Recommended on (A) evidence, high confidence. The criteria are the guideline's three, and all three must be present. A denial against a note that documents all three is worth appealing.