Utilization Review Checklist
Hip Osteonecrosis (Avascular Necrosis)
Derived from the ACOEM Hip and Groin Disorders Guideline, edition 29 January 2026, as adopted into the California MTUS 1 August 2026. CPT 27130, 27299. ICD-10 M87.05.
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, with the presence or absence of femoral head collapse stated
“Patients with collapse of the femoral head are immediate candidates for arthroplasty.” — p. 206
Conservative Care
Required
Response or non-response to risk factor modification
“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 with hyperbaric oxygen is felt to be too risky.” — p. 205
Procedures — the guideline treats each separately
Core decompression surgery
Recommended. Core decompression surgery is recommended for treatment of osteonecrosis.
Strength of Evidence — Recommended, Insufficient Evidence (I) · confidence low · p. 205
Indications — required:
Generally moderate to severe osteonecrosis
“Core decompression surgery is recommended for treatment of osteonecrosis.” — p. 205
The joint-preserving option, for moderate to severe osteonecrosis that is either not responding to risk factor modification OR felt to be at risk of collapse where further delay is too risky. Note it is an either/or — you do not need both. If the femoral head has already collapsed, arthroplasty is the far better-supported route.
Arthroplasty for osteonecrosis with collapse or severe unresponsive disease
Strongly Recommended. Arthroplasty is strongly recommended for treatment of osteonecrosis with collapse or severe disease unresponsive to non-operative treatment.
Strength of Evidence — Strongly Recommended, Evidence (A) · confidence high · p. 206
Indications — required:
Collapse of the femoral head, or severe osteonecrosis unresponsive to risk factor modification or at significant risk of immediate collapse
“Indications Patients with collapse of the femoral head are immediate candidates for arthroplasty. Additional candidates include those with severe osteonecrosis who are: (i) unresponsive to risk factor modification, and/or (ii) felt to be at significant risk of immediate collapse.” — p. 206
Strongly Recommended on (A) evidence at High confidence — one of the strongest recommendations in any of these chapters. The guideline says patients with COLLAPSE of the femoral head are IMMEDIATE candidates, with no conservative requirement at all. Document the collapse and cite that.