Lateral and Medial Epicondylalgia

Utilization Review Checklist

Derived from the ACOEM Elbow Disorders Guideline, edition 14 July 2025, as adopted into the California MTUS 2 January 2026. CPT 24357, 24358, 24359, 24999. ICD-10 M77.1, M77.0.

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.

Patient name: Claim #:

CriteriaCheck if documented

Confirmatory Diagnosis

Any one of the following

Confirmed diagnosis of lateral epicondylalgia
“A confirmed diagnosis of lateral epicondylalgia requires all of the following:” — p. 126
All of the following:
- Lateral elbow pain
  “● lateral elbow pain,” — p. 126
- AND
  Tenderness over the lateral epicondyle or just distal to the epicondyle
  “● tenderness over the lateral epicondyle or just distal to the epicondyle, and” — p. 126
- AND
  Pain with resisted wrist extension or resisted middle finger extension
  “● pain with resisted wrist extension or resisted middle finger extension.” — p. 126
OR
Confirmed diagnosis of medial epicondylalgia
“A confirmed diagnosis of medial epicondylalgia requires all of the following:” — p. 126
All of the following:
- Medial elbow pain
  “● medial elbow pain,” — p. 126
- AND
  Tenderness over the medial epicondyle or just distal to the epicondyle
  “● tenderness over the medial epicondyle or just distal to the epicondyle, and” — p. 126
- AND
  Pain with resisted wrist flexion
  “● pain with resisted wrist flexion.” — p. 126

Conservative Care

All of the following

Pain generally for at least 6 months — at least 6 months
“● pain generally for at least 6 months , although some limited exceptions where as little as 3 months of nonoperative management may be sufficient, and” — p. 126
AND
Insufficiently responsive to non-operative treatments including NSAIDs, elbow straps, stretching and strengthening exercises
“● insufficiently responsive to non-operative treatments including NSAIDs, elbow straps, stretching and strengthening exercises” — p. 126

Procedures — the guideline treats each separately

Surgical epicondylar release for chronic epicondylalgia

Recommended. Surgical epicondylar release is recommended for the treatment of chronic lateral or medial epicondylalgia.

Strength of Evidence — Recommended, Insufficient Evidence (I) · p. 125

Indications — required:

Epicondylar release requested for chronic epicondylalgia
“Any of the three main surgical approaches are acceptable pending quality trials to further direct care (open, percutaneous and arthroscopic).” — p. 126

Open, percutaneous and arthroscopic approaches are all acceptable to the guideline — it declines to prefer one pending better trials, so the approach chosen is not a ground for denial. The evidence grade is Insufficient (I), so the six months of symptoms and the failed non-operative trial are what carry the request.

Radiofrequency microtenotomy for chronic epicondylalgia

Recommended. Radiofrequency microtenotomy is recommended for the treatment of chronic lateral or medial epicondylalgia

Strength of Evidence — Recommended, Evidence (C) · p. 127

Indications — required:

Radiofrequency microtenotomy requested for chronic epicondylalgia
“Radiofrequency microtenotomy is recommended for the treatment of chronic lateral or medial epicondylalgia” — p. 127

Microtenotomy carries a STRONGER evidence grade than open release — (C) against Insufficient (I) — on the same criteria. Worth naming explicitly if it is the procedure you intend, because the grade is the better one to be judged against.