Utilization Review Checklist
Scaphoid Fracture
Derived from the ACOEM Hand, Wrist and Forearm Disorders Guideline, edition 14 July 2025, as adopted into the California MTUS 2 January 2026. CPT 25628, 25645. ICD-10 S62.0.
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.
CriteriaCheck if documented
Confirmatory Diagnosis
Required
Scaphoid fracture with displacement stated
“Surgical fixation of displaced scaphoid fractures is recommended.” — p. 278
Procedures — the guideline treats each separately
Surgical fixation of a displaced scaphoid fracture
Recommended. Surgical fixation of displaced scaphoid fractures is recommended.
Strength of Evidence — Recommended, Insufficient Evidence (I) · confidence high · p. 278
Indications — required:
Displaced fracture, fixation requested
“Surgical fixation of displaced scaphoid fractures is recommended.” — p. 278
High confidence. Displacement is the whole criterion — the guideline says displaced fractures are believed to require fixation. Quote the displacement from the report.
Surgical fixation of a non-displaced or minimally displaced scaphoid fracture for a patient requiring earlier functional recovery
Recommended. Surgical intervention of treatment of non-displaced or minimally displaced scaphoid fractures is recommended for patients requiring earlier functional recovery.
Strength of Evidence — Recommended, Evidence (C) · confidence low · p. 279
Indications — required:
Patient requires earlier functional recovery, cannot or does not wish to attempt non-operative treatment
“Indications Patients with non-displaced or minimally displaced scaphoid fractures who cannot or do not wish to be treated with an attempt at non-operative treatment. This includes athletes.” — p. 279
The SAME fracture has two opposite recommendations in this chapter, separated only by whether the patient requires earlier functional recovery. This is the supported half. Document why early recovery is required — the guideline names athletes and patients unable to tolerate prolonged immobilisation, and in an occupational claim the job demands make the same argument.
Surgical fixation of a non-displaced or minimally displaced scaphoid fracture for all other patients
Not Recommended. Surgical intervention for treatment of non-displaced or minimally displaced scaphoid fractures is not recommended for all other patients.
Strength of Evidence — Not Recommended, Evidence (C) · confidence low · p. 280
Indications — required:
Non-displaced fracture, patient not requiring earlier functional recovery
“Surgical intervention for treatment of non-displaced or minimally displaced scaphoid fractures is not recommended for all other patients.” — p. 280
Not recommended for patients who do NOT require earlier functional recovery — the guideline records no quality evidence of improved long-term outcomes with surgery for non-displaced fractures. Before filing, ask whether this patient genuinely needs early recovery: if so, the other recommendation supports the same operation.