Utilization Review Checklist
Initial Approaches to Treatment — Medications, Physical Methods, Telehealth and Home Health Care
Derived from the ACOEM Initial Approaches to Treatment Guideline, edition 22 December 2025, as adopted into the California MTUS 1 June 2026. CPT 99500, 99600, 97110, 99441, 99442, 99443. ICD-10 Z51.89, Z74.09, Z99.89.
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
Home health care services following hospitalization or major surgery
Recommended.
Strength of Evidence — Recommended, Insufficient Evidence (I) · confidence moderate
Indications
Any one of the following
Home health care services following hospitalization or major surgery
“Home healthcare is selectively recommended on a short-term basis following hospitalization and major surgical procedures.” — p. 16
Required:
Short-term home health care following hospitalization or a major surgical procedure
“Home healthcare is selectively recommended on a short-term basis following hospitalization and major surgical procedures.” — p. 16
Contraindications and Cautions
Required
Unable to leave home without major assistance, or leaving home is not medically advised, AND normally unable to leave home with leaving being a major effort
“the patient is normally unable to leave home and leaving home is a major effort.” — p. 16
Selectively recommended short-term after hospitalization and major surgical procedures. The indications are a homebound test: unable to leave home without major assistance, or leaving home not medically advised, AND normally unable to leave home with leaving being a major effort. Requests usually fail on the homebound test rather than on the surgery.
Medication trial — one at a time, for a specific goal
Recommended.
Strength of Evidence — Recommended, Evidence (C) · confidence high
Indications
Any one of the following
Medication trial — one at a time, for a specific goal
“Generally, a trial of one medication for a specific goal (e.g. pain reduction) should be provided at a time.” — p. 12
Required:
A trial of one medication at a time for a specific goal, with evidence of efficacy
“Generally, a trial of one medication for a specific goal (e.g. pain reduction) should be provided at a time.” — p. 12
Dose, Duration and Discontinuation
All of the following
Ineffective medication or treatment is discontinued before an alternative is provided, with effects documented against objective or functional improvement
“Ineffective medication(s) should be discontinued prior to provision of alternate medication(s)” — p. 12
AND
Effects documented with attention to objective and/or functional improvements
“The effects of a medication should be documented, with attention to objective and/or functional improvements.” — p. 12
Recommended on Evidence (C) at High confidence. One medication at a time for a specific goal; two and infrequently three may be reasonable in select cases, especially acute. Ineffective medication must be discontinued before an alternative is provided.
Physical method — one treatment at a time, with documented effect
Recommended. Patients should be provided a treatment that has quality evidence of efficacy.
Strength of Evidence — Recommended, Insufficient Evidence (I) · confidence high · p. 14
Indications — required:
A physical method with quality evidence of efficacy, provided one at a time
“Patients should be provided a treatment that has quality evidence of efficacy.” — p. 14
The guideline suggests prescribing approximately 4 to 6 appointments and observing for functional gain, and states there is no specific limit on the number of appointments — a useful sentence to quote when a visit cap is applied without reference to function.
Distance-based (telehealth) services
Recommended. Distance-based (telehealth) services are selectively recommended.
Strength of Evidence — Recommended, Insufficient Evidence (I) · confidence low · p. 15
Indications — required:
Distance-based (telehealth) services are selectively recommended
“Distance-based (telehealth) services are selectively recommended.” — p. 15
Selectively recommended, on Insufficient Evidence at Low confidence.