Utilization Review Checklist
Distal Biceps Rupture
Derived from the ACOEM Elbow Disorders Guideline, edition 14 July 2025, as adopted into the California MTUS 2 January 2026. CPT 24342, 24341. ICD-10 S53.1, M66.82.
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
Any one of the following
Complete or large distal biceps tendon rupture
“Indications Biceps tendon ruptures that are either complete, large or in select patients with moderately severe biceps tendinosis patients who fail to adequately progress with non-operative care with which they have demonstrated compliance.” — p. 27
OR
Moderate tear in a patient with high job physical demands
“Patients with high job physical demands but only moderate tears are also candidates for surgery to attempt to regain sufficient function to return to those job tasks.” — p. 27
Conservative Care
Required
For moderately severe tendinosis: failure to adequately progress with non-operative care, with demonstrated compliance
“in select patients with moderately severe biceps tendinosis patients who fail to adequately progress with non-operative care with which they have demonstrated compliance.” — p. 27
Surgical Considerations (surgical repair)
Required
Repair of the distal biceps rupture requested
“Surgical repair of distal biceps ruptures is recommended.” — p. 27
Procedures — the guideline treats each separately
Surgical repair of a distal biceps rupture
Recommended.
Strength of Evidence — Recommended, Insufficient Evidence (I)
Three separate routes, and the third is the useful one in an occupational claim: a complete tear, OR a large tear, OR — for a patient with HIGH JOB PHYSICAL DEMANDS — even a moderate tear, to regain enough function to return to those tasks. If the tear is moderate, document the job demands concretely; that is the route the guideline opens for exactly this situation.