Utilization Review Checklist
Bicipital Tendinopathy and Ruptured Bicipital Tendon
Derived from the ACOEM Shoulder Disorders Guideline, edition 14 July 2025, as adopted into the California MTUS 2 January 2026. CPT 23430, 23440. ICD-10 M75.2, S46.1.
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
Complete bicipital tendon tear
“Surgery is recommended for select patients with complete bicipital tendon tears.” — p. 221
Procedures — the guideline treats each separately
Surgery, usually tenodesis, for a complete bicipital tendon tear
Recommended. Surgery is recommended for select patients with complete bicipital tendon tears.
Strength of Evidence — Recommended, Insufficient Evidence (I) · confidence low · p. 221
Indications — all of the following:
Significant incapacity due to the tear
“Rare patients with significant incapacity due to the tear, generally having very high physically-demanding jobs, as the long head and bicipital tendon play a negligible role in the dynamic stability and/or strength of the shoulder.” — p. 221
AND
Generally having very high physically-demanding jobs
“generally having very high physically-demanding jobs,” — p. 221
Set expectations before filing. The guideline says the long head of biceps plays a negligible role in shoulder stability and strength, that rupture may be managed non-operatively for the vast majority with no accompanying functional disability, and that the primary indications are cosmesis and potentially intolerable pain. It reserves surgery for RARE patients with significant incapacity, generally in very high physically-demanding jobs. That is a narrow gate — document the incapacity and the job demands concretely or the request reads as one of the vast majority. The guideline also states no preference between tenodesis and tenotomy, so the choice between them is not a ground for denial.
Rotator cuff repair performed at the same time as treatment for bicipital tendinopathy
No Recommendation. Rotator cuff repair surgery has been performed at the same time as treatment for bicipital tendinopathy.
Strength of Evidence — No Recommendation, Insufficient Evidence (I) · confidence low · p. 222
Indications — required:
Rotator cuff repair requested together with treatment for bicipital tendinopathy
“Rotator cuff repair surgery has been performed at the same time as treatment for bicipital tendinopathy.” — p. 222
ACOEM gives no recommendation either way on doing these together, and refers the reader to the Rotator Cuff Tendinopathy section. That is neutrality, not a refusal. The practical route is to justify the rotator cuff repair on its own criteria — see acoem-shoulder-rotator-cuff, where repair of a small to large tear is Moderately Recommended on (B) evidence — rather than resting the request on the combination.
Tenodesis or tenotomy for biceps tendinopathy in combination with rotator cuff tears
No Recommendation. There is no recommendation for tenodesis or tenotomy for treatment of long head of the biceps tendinopathy in combination with rotator cuff tears.
Strength of Evidence — No Recommendation, Insufficient Evidence (I) · confidence low · p. 223
Indications — required:
Tenodesis or tenotomy requested for biceps tendinopathy with a rotator cuff tear
“There is no recommendation for tenodesis or tenotomy for treatment of long head of the biceps tendinopathy in combination with rotator cuff tears.” — p. 223
No recommendation for or against. The reason is informative: multiple trials show no significant difference between tenodesis and tenotomy, between high and subpectoral tenodesis, between suprapectoral and open subpectoral tenodesis, and at four years between detaching and not detaching the tendon. The guideline is neutral because the techniques perform alike, not because the procedure is doubted — so an argument about which technique is superior will not move a reviewer.