Draft — pending COA review. Rette derived these criteria from the ACOEM guidelines adopted into the MTUS. They are not COA documents and have not been signed off by a COA physician reviewer.

MTUS Treatment ChecklistbyRette

Utilization Review Checklist

Elbow Fracture

Derived from the ACOEM Elbow Disorders Guideline, edition 14 July 2025, as adopted into the California MTUS 2 January 2026. CPT 24579, 24586, 24665. ICD-10 S42.4, S52.0.

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.

Patient name: Claim #:

CriteriaCheck if documented

Confirmatory Diagnosis

Required

  • Displaced elbow fracture

    “Surgical fixation is recommended for displaced elbow fractures.” — p. 49

Surgical Considerations (surgical fixation)

All of the following

  • Fixation, or radial head excision or replacement for widely displaced or comminuted fractures

    “Widely displaced fracture and/or comminuted fragments may require radial head excision and/o” — p. 49

  • AND

    Fixation requested promptly after injury

    “Surgical fixation is recommended for displaced elbow fractures.” — p. 49

Procedures — the guideline treats each separately

Surgical fixation of a displaced elbow fracture

Recommended.

Strength of Evidence — Recommended, Insufficient Evidence (I)

The criterion is displacement. The guideline notes many of these fractures do not do well without surgery, and that widely displaced or comminuted fractures may require radial head excision or replacement — so describe the displacement and comminution from the report. It also records one trial finding two types of fixation comparable, so the implant choice is not a ground for denial.

Reviewing this for COA, or think a criterion is wrong?