Utilization Review Checklist
Elbow Dislocation and Instability
Derived from the ACOEM Elbow Disorders Guideline, edition 14 July 2025, as adopted into the California MTUS 2 January 2026. CPT 24343, 24346. ICD-10 S53.1, M24.42.
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
Recurrent elbow dislocations and/or an unstable elbow after dislocation
“Indications Recurrent elbow dislocations and/or unstable elbows after dislocation(s).” — p. 40
Surgical Considerations (stabilisation)
All of the following
Instability due to ligament and/or capsular damage and laxity
“However, some have unstable joints due to ligament and/or capsular damage and laxi” — p. 40
AND
Stabilisation requested
“Surgery is recommended to repair elbow joints that either recurrently dislocate or are otherwise unstable after dislocation(s).” — p. 40
Procedures — the guideline treats each separately
Surgery for elbows that recurrently dislocate or are unstable after dislocation
Recommended.
Strength of Evidence — Recommended, Insufficient Evidence (I)
The guideline notes most patients do NOT require surgery after an elbow dislocation, so the case rests on showing this elbow is one of the exceptions: recurrent dislocation, or demonstrable instability after dislocation from ligament or capsular damage. Document the instability on examination rather than inferring it from symptoms.