Utilization Review Checklist
Labral Tears, including SLAP Tears
Derived from the ACOEM Shoulder Disorders Guideline, edition 14 July 2025, as adopted into the California MTUS 2 January 2026. CPT 29807, 29806. ICD-10 S43.43, M24.11.
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
Any one of the following
Non-radiating shoulder joint pain
“Symptoms generally include non-radiating shoulder joint pain,” — p. 470
OR
Increased pain with overhead activity
“increased pain with overhead activity,” — p. 470
OR
Painful catching or popping sensations
“and painful catching or popping sensations” — p. 470
Confirmatory Diagnosis
All of the following
MRA or MRI findings and clinical suspicion of labral or SLAP tear
“Symptoms with MRA or MRI findings and clinical suspicion of labral or SLAP tear that do not symptomatically resolve after a minimum of approximately 6 weeks of non-operative treatment.” — p. 500
AND
MRA findings should generally be larger tears, e.g. Snyder Type III or IV
“MRA findings should generally be larger tears (e.g., Snyder Type III or IV).” — p. 500
Conservative Care
Required
Symptoms that do not resolve after a minimum of approximately 6 weeks of non-operative treatment — at least 6 weeks
“that do not symptomatically resolve after a minimum of approximately 6 weeks of non-operative treatment.” — p. 500
Surgical Considerations (arthroscopic and/or open repair)
Required
Arthroscopic or open repair requested for a select labral or SLAP tear
“Arthroscopic or open surgery is selectively recommended for select treatment of labral or superior labral anterior posterior (SLAP) tears, especially Type III and Type IV.” — p. 500
Procedures — the guideline treats each separately
Arthroscopic and/or open surgery for labral or SLAP tears
Recommended.
Strength of Evidence — Recommended, Insufficient Evidence (I) · confidence low
Read the tear TYPE and the patient's AGE before filing. The recommendation is for "select treatment ... especially Type III and Type IV", and the guideline records a high-quality RCT showing repair of Type II tears is no better than sham surgery, with no sick-leave or return-to-work benefit. It also states most individuals over 40 do not appear to require repair. A Type II request, or a request in a patient over 40, is filed against the weakest part of this recommendation — say why this patient is one of the minority the guideline allows for.