Utilization Review Checklist
Rotator Cuff Tear and Tendinopathy
Derived from the ACOEM Shoulder Disorders Guideline, edition 14 July 2025, as adopted into the California MTUS 2 January 2026. CPT 29827, 23412, 23472, 29826. ICD-10 M75.1, M75.4.
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
Shoulder joint pain that increases with overhead use
“● shoulder joint pain that increases with overhead use and” — p. 183
AND
Shoulder joint pain and/or weakness with resisted abduction
“● shoulder joint pain and/or weakness with resisted abduction.” — p. 183
Confirmatory Diagnosis
Any one of the following
MRI
“A confirmatory diagnosis or RCT requires supportive findings from one of the following: ● MRI, ● MRA, ● diagnostic US and/or arthroscopic surgery.” — p. 183
OR
MRA
“A confirmatory diagnosis or RCT requires supportive findings from one of the following: ● MRI, ● MRA, ● diagnostic US and/or arthroscopic surgery.” — p. 183
OR
Diagnostic US and/or arthroscopic surgery
“● diagnostic US and/or arthroscopic surgery.” — p. 183
Procedures — the guideline treats each separately
Rotator cuff repair for small, medium or large tears (<5 cm)
Moderately Recommended. Rotator cuff repair is moderately recommended for selective treatment of small, medium, or large tears (<5 cm).
Strength of Evidence — Moderately Recommended, Evidence (B) · confidence moderate · p. 183
Indications — all of the following:
Shoulder joint pain
“Surgical considerations for small, medium and large RCTs include all of the following: ● shoulder joint pain,” — p. 184
AND
Reduced range of motion and/or impaired function, and imaging demonstrating a complete rotator cuff tear
“● reduced range of motion and/or impaired function and imaging demonstrating a complete rotator cuff tear.” — p. 184
The best-supported repair in this section — Moderately Recommended on (B) evidence. The guideline notes evidence of superiority over non-operative care for small to medium tears at five to ten years, which is worth citing if a reviewer proposes more therapy.
Rotator cuff repair for acute massive tears (>5 cm)
Recommended. Rotator cuff repair is selectively recommended for treatment of acute massive tears (>5 cm).
Strength of Evidence — Recommended, Evidence (C) · confidence low · p. 189
Indications — all of the following:
Shoulder joint pain
“All of the following: 1) shoulder joint pain; 2) reduced range of motion of the shoulder or impaired function; 3) imaging findings by MRI, MR arthrography, or ultrasound of massive rotator cuff tear.” — p. 189
AND
Reduced range of motion of the shoulder or impaired function
“2) reduced range of motion of the shoulder or impaired function;” — p. 189
AND
Imaging findings by MRI, MR arthrography, or ultrasound of massive rotator cuff tear
“3) imaging findings by MRI, MR arthrography, or ultrasound of massive rotator cuff tear.” — p. 189
Selectively recommended for ACUTE massive tears. The distinction from chronic matters enormously: the same repair on a chronic massive tear is Not Recommended. Date the injury and say the tear is acute. The guideline adds that younger, healthier patients are better candidates.
Rotator cuff repair for chronic massive tears (>5 cm)
Not Recommended. Rotator cuff repair is not generally recommended for treatment of chronic massive tears (>5 cm).
Strength of Evidence — Not Recommended, Evidence (C) · confidence low · p. 191
Indications — required:
Repair requested for a chronic massive tear
“Rotator cuff repair is not generally recommended for treatment of chronic massive tears (>5 cm).” — p. 191
The guideline does NOT recommend repair of a chronic massive tear. If the tear is unrepairable or has failed repair and there is significant fatty infiltration, reverse shoulder arthroplasty is the route the guideline does support — request that instead.
Reverse shoulder arthroplasty for large to massive unrepairable tears
Recommended. Reverse shoulder arthroplasty is recommended for treatment of select large to massive cuff tears that are otherwise unrepairable.
Strength of Evidence — Recommended, Insufficient Evidence (I) · confidence low · p. 187
Indications — all of the following:
Shoulder joint pain
“Surgical considerations include all of the following: ● shoulder joint pain,” — p. 188
AND
Reduced range of motion and/or impaired function
“● reduced range of motion and/or impaired function,” — p. 188
AND
Imaging demonstrating a large to massive complete rotator cuff tear
“● imaging demonstrating a large to massive complete rotator cuff tear, and” — p. 188
AND
Either an unrepairable tear, failed surgical repair, or significant fatty infiltration
“● either an unrepairable tear, failed surgical repair, or significant fatty infiltration” — p. 188
Recommended for select large to massive tears that are otherwise unrepairable. The fourth criterion is the one that carries it — unrepairable tear, failed repair, or significant fatty infiltration — so quote the imaging or the operative note that establishes it. The guideline also calls a quality postoperative rehabilitation programme essential; say one is planned.
Subacromial decompression for impingement syndrome / rotator cuff tendinoses
Recommended. Subacromial decompression surgery is recommended for treatment of select patients with impingement syndrome/rotator cuff tendinoses.
Strength of Evidence — Recommended, Evidence (C) · confidence low · p. 196
Indications — all of the following:
Shoulder joint pain, symptomatic with positive supraspinatus test or impingement signs
“All of the following: ● shoulder joint pain (e.g., symptomatic with positive supraspinatus test, impingement signs);” — p. 196
AND
Reduced active shoulder range of motion or impaired function
“● reduced active shoulder ROM or impaired function” — p. 196
AND
Imaging findings by MRI or ultrasound of rotator cuff tendinopathy consistent with symptoms
“● imaging findings by MRI or ultrasound of rotator cuff tendinopathy consistent with symptoms; and” — p. 196
AND
Temporary resolution or marked reduction in pain immediately after injection of a local anaesthetic into the subacromial space
“● temporary resolution or marked reduction in pain immediately after injection of a local anesthetic into the subacromial space.” — p. 196
AND
Failed one or more glucocorticosteroid injections and at least one trial of a quality rehabilitation program
“Patients should also have failed one or more glucocorticosteroid injections (see above) and at least one trial of a quality rehabilitation program that follows evidence-based guidelines (see above).” — p. 196
Recommended only after other treatments have failed, and it has an extra requirement no other path here has: temporary resolution or marked reduction in pain immediately after a local anaesthetic injection into the subacromial space. The guideline also treats scapular dyskinesia as a relative contraindication, so state that it is absent or has been treated.
Rotator cuff repair for massive tears using porcine xenograft material
Not Recommended. Porcine small intestine submucosa graft for surgical repair is not recommended for treatment of large or massive tears that are otherwise unrepairable.
Strength of Evidence — Not Recommended, Evidence (C) · confidence low · p. 192
Indications — required:
Repair using porcine small intestine submucosa graft requested
“Porcine small intestine submucosa graft for surgical repair is not recommended for treatment of large or massive tears that are otherwise unrepairable.” — p. 192
The guideline does NOT recommend porcine small intestine submucosa graft for large or massive otherwise-unrepairable tears. Tissue augmentation carries No Recommendation rather than a negative one. For an unrepairable tear the supported route is reverse shoulder arthroplasty.
Adding claviculectomy or subacromial decompression to a rotator cuff repair for isolated supraspinatus tears
Moderately Not Recommended. Adding claviculectomy or subacromial decompression to a rotator cuff repair is moderately not recommended for treatment of isolated supraspinatus tears.
Strength of Evidence — Moderately Not Recommended, Evidence (B) · confidence moderate · p. 198
Indications — required:
Claviculectomy or subacromial decompression added to a rotator cuff repair for an isolated supraspinatus tear
“Adding claviculectomy or subacromial decompression to a rotator cuff repair is moderately not recommended for treatment of isolated supraspinatus tears.” — p. 198
Moderately Not Recommended on (B) evidence — one of the better-evidenced negative findings in the chapter. If you are repairing an isolated supraspinatus tear, adding a claviculectomy or subacromial decompression is likely to be denied and the evidence against it is good. Request the repair alone.