Utilization Review Checklist
Pronator Syndrome (forearm median neuropathy)
Derived from the ACOEM Elbow Disorders Guideline, edition 14 July 2025, as adopted into the California MTUS 2 January 2026. CPT 24495, 64721. ICD-10 G56.1.
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
Symptoms of median neuropathy in the forearm with significant loss of function
“Indications Symptoms of median neuropathy in the forearm, and a significant loss of function, as reflected in significant activity limitations due to the nerve entrapment” — p. 145
Surgical Considerations (surgical release)
Any one of the following
Failure of non-operative treatment for subacute or chronic forearm median neuropathy
“Surgical release is recommended for patients who fail non-operative treatment for subacute or chronic median neuropathies in the forearm.” — p. 145
OR
Emergent or urgent indications, such as acute compression due to fracture or compartment syndrome with unrelenting symptoms of nerve impairment
“It is also recommended for patients who have emergent or urgent indications (e.g., acute compression due to fracture, or compartment syndrome with unrelenting symptoms of nerve impairment).” — p. 145
Procedures — the guideline treats each separately
Surgical release for subacute or chronic forearm median neuropathy
Recommended.
Strength of Evidence — Recommended, Insufficient Evidence (I)
The indication asks for significant LOSS OF FUNCTION, reflected in significant activity limitations due to the nerve entrapment — not merely symptoms. There is also an emergent route: acute compression from fracture, or compartment syndrome with unrelenting symptoms of nerve impairment, which does not wait on a conservative trial.