Utilization Review Checklist
Adhesive Capsulitis
Derived from the ACOEM Shoulder Disorders Guideline, edition 14 July 2025, as adopted into the California MTUS 2 January 2026. CPT 23700, 29825, 23020. ICD-10 M75.0.
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
Adhesive capsulitis with pain and loss of motion, moderate to severely affected
“Adhesive capsulitis, especially moderate to severely affected patients with pain and loss of motion.” — p. 372
Conservative Care
Required
Insufficient response to NSAIDs, exercises, and steroid injection(s)
“Should be reserved for patients who do not respond sufficiently to NSAIDs, exercises, and steroid injection(s)” — p. 372
Procedures — the guideline treats each separately
Hydrodilatation
Recommended. Hydrodilatation is selectively recommended for treatment of adhesive capsulitis.
Strength of Evidence — Recommended, Insufficient Evidence (I) · confidence low · p. 372
Indications — required:
Hydrodilatation requested after insufficient response to NSAIDs, exercises and steroid injection(s)
“Hydrodilatation is selectively recommended for treatment of adhesive capsulitis.” — p. 372
The first rung of the ladder. Reserved for patients not responding sufficiently to NSAIDs, exercises and steroid injections. The guideline is candid that the trials conflict and that hydrodilatation appears inferior to arthroscopic release. On repeats it is explicit: if there is no improvement after one procedure a second is NOT recommended; if range of motion objectively improved but incompletely, a second may be selectively indicated. Record the objective gain if you are asking for a second.
Manipulation under anaesthesia
Recommended. Manipulation under anesthesia is recommended for treatment of adhesive capsulitis in select patients.
Strength of Evidence — Recommended, Evidence (C) · confidence low · p. 348
Indications — all of the following:
Loss of active motion with insufficient response to NSAIDs, steroid injection(s), and hydrodilatation
“Adhesive capsulitis, especially moderate to severely affected patients with pain and loss of active motion who do not respond sufficiently to NSAIDs, steroid injection(s), and hydrodilatation” — p. 349
AND
Treatment combined with post-procedure exercises, with adequate safe anaesthetic monitoring
“Generally, only 1 treatment performed; adequate, safe monitoring of anesthesia is required. A second procedure would be potentially recommended based on incremental gain from the first but an incomplete and insufficiently satisfactory result. Treatment should be combined with post-procedure exercises.” — p. 349
Second rung, and note it requires HYDRODILATATION to have been tried as well as NSAIDs and steroid injections — that prerequisite is the one most often missing. The guideline asks for loss of ACTIVE motion specifically, says treatment should be combined with post-procedure exercises, and requires adequate safe anaesthetic monitoring. It also records that one trial found hydrodilatation superior to MUA.
Arthroscopic surgery
Recommended. Arthroscopy is recommended for evaluation of select patients with adhesive capsulitis, including subsequent, definitive operative approaches.
Strength of Evidence — Recommended, Evidence (C) · confidence high · p. 373
Indications — all of the following:
Severely affected, not responding sufficiently to NSAIDs, exercise, injection(s), and potentially hydrodilatation or MUA
“Adhesive capsulitis in severely affected patients with pain and loss of motion who do not respond sufficiently to NSAIDs, exercise, injection(s), and potentially to hydrodilatation or” — p. 373
AND
A believed remediable, intra-articular or periarticular defect that is able to be addressed surgically
“and in whom there is believed to be a remediable, intra-articular or periarticular defect that is able to be addressed surgically” — p. 374
Any one of the following:
Rotator cuff tear with surgical indications
“● rotator cuff tear with surgical indications and the expectation that surgical treatment will immediately follow arthroscopy (see below);” — p. 374
OR
Labral tear with surgical indications
“● labral tear with surgical indications (see below);” — p. 374
OR
Impingement syndrome with surgical indications
“● impingement syndrome with surgical indications (see below);” — p. 374
OR
Glenohumeral instability
“● glenohumeral instability,” — p. 374
OR
Recurrent dislocations
“● recurrent dislocations,” — p. 374
OR
Other moderate or severe shoulder joint pain
“● other moderate or severe shoulder joint pain, or” — p. 374
OR
Acromioclavicular arthritis
“● acromioclavicular arthritis.” — p. 374
The strongest footing in this section — Recommended on (C) evidence at HIGH confidence, and two trials suggest arthroscopic release beats glucocorticoid injection. But it carries an extra requirement no other path has: a believed remediable intra-articular or periarticular defect that can be addressed surgically. Name which one — the guideline lists seven. Without it the request is an arthroscopy for stiffness alone, which is not what this recommendation covers.
Open release of contractures
Recommended. Open release surgery is selectively recommended for patients with adhesive capsulitis.
Strength of Evidence — Recommended, Insufficient Evidence (I) · confidence low · p. 375
Indications — all of the following:
Insufficient response to NSAIDs, injection(s), exercise, hydrodilatation and manipulation under anaesthesia
“Adhesive capsulitis, especially severely affected patients with pain and limited range of motion who do not respond sufficiently to NSAIDs, injection(s), exercise, hydrodilatation, manipulation under anesthesia and generally only if there is another coexistent disorder that is felt to require open surgical procedure(s) to resolve” — p. 375
AND
Generally only if there is another coexistent disorder felt to require open surgical procedure(s) to resolve
“and generally only if there is another coexistent disorder that is felt to require open surgical procedure(s) to resolve” — p. 375
The last rung and the weakest evidence — there are no quality trials of open release at all. It requires everything below it to have failed, INCLUDING hydrodilatation and manipulation under anaesthesia, and generally requires another coexistent disorder that needs an open procedure to resolve. The guideline also says that if one surgical approach fails there is generally no indication to repeat it.