Utilization Review Checklist
Ankle Fracture
Derived from the ACOEM Ankle and Foot Disorders Guideline, edition 29 January 2026, as adopted into the California MTUS 1 August 2026. CPT 27766, 27769, 27792, 27814, 27822. ICD-10 S82.5, S82.6, S82.8.
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
Closed ankle fracture, with instability and displacement described
“Operative fixation is recommended for unstable closed displaced ankle fractures.” — p. 125
Procedures — the guideline treats each separately
Operative fixation for unstable closed displaced ankle fractures
Recommended. Operative fixation is recommended for unstable closed displaced ankle fractures.
Strength of Evidence — Recommended, Evidence (C) · confidence high · p. 125
Indications — required:
Fixation requested for an unstable closed displaced fracture
“Operative fixation is recommended for unstable closed displaced ankle fractures.” — p. 125
Recommended on (C) evidence at HIGH confidence. Two words carry it — unstable and displaced — so both belong in the imaging description.
Operative fixation for closed ankle fractures with unstable syndesmotic rupture
Recommended. Operative fixation is recommended for closed ankle fractures with unstable syndesmotic rupture.
Strength of Evidence — Recommended, Insufficient Evidence (I) · confidence high · p. 129
Indications — required:
AO fracture type C and/or pathologic widening of more than 2mm of the syndesmosis at intra-operative testing
“Indications Closed ankle fractures with unstable syndesmosis, AO fracture type C and/or pathologic widening of more than 2mm of the syndesmosis at intra-operative testing (Hoiness et al., 2004).” — p. 129
High confidence, and the indication is unusually precise: AO fracture type C and/or pathologic widening of MORE THAN 2 mm of the syndesmosis at intra-operative testing. If you have the measurement, quote it — few indications in these chapters are this checkable.
Deltoid ligament repair concurrent with ORIF for unstable ankle fractures
Not Recommended. Performing repair of torn deltoid ligament in association with ORIF for ankle fracture is not recommended.
Strength of Evidence — Not Recommended, Insufficient Evidence (I) · confidence moderate · p. 130
Indications — required:
Deltoid ligament repair requested alongside ORIF
“Performing repair of torn deltoid ligament in association with ORIF for ankle fracture is not recommended.” — p. 130
Not recommended as an ADD-ON. The fixation itself is recommended; repairing a torn deltoid ligament at the same sitting is not. Request the ORIF without it.