Utilization Review Checklist
Radial Nerve Entrapment at the Wrist
Derived from the ACOEM Hand, Wrist and Forearm Disorders Guideline, edition 14 July 2025, as adopted into the California MTUS 2 January 2026. CPT 64708, 64721. ICD-10 G56.3.
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
Subacute or chronic radial nerve compression neuropathy at the wrist
“Surgical release is recommended for subacute or chronic cases of radial nerve compression neuropathy that persist despite other interventions (Plate et al., 2000).” — p. 403
Conservative Care
Required
Symptoms persist despite other interventions
“Surgical release is recommended for subacute or chronic cases of radial nerve compression neuropathy that persist despite other interventions (Plate et al., 2000).” — p. 403
Surgical Considerations (surgical release)
Required
Release requested at the site of compression
“Surgical release is recommended for subacute or chronic cases of radial nerve compression neuropathy that persist despite other interventions (Plate et al., 2000).” — p. 403
Procedures — the guideline treats each separately
Surgical release for subacute or chronic radial nerve compression neuropathy
Recommended.
Strength of Evidence — Recommended, Insufficient Evidence (I) · confidence moderate
The criterion is persistence DESPITE OTHER INTERVENTIONS. The guideline sets no duration and names no specific treatments here, so what carries the request is a clear account of what was tried and that the symptoms continued through it.