Draft — pending COA review. Rette derived these criteria from the ACOEM guidelines adopted into the MTUS. They are not COA documents and have not been signed off by a COA physician reviewer.

MTUS Treatment ChecklistbyRette

Utilization Review Checklist

Radial Nerve Entrapment

Derived from the ACOEM Elbow Disorders Guideline, edition 14 July 2025, as adopted into the California MTUS 2 January 2026. CPT 24495, 64708, 64712. ICD-10 G56.3.

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

Presumptive Diagnosis

Required

  • Pain and tenderness in the proximal lateral forearm, distal to the lateral epicondyle

    “A presumptive diagnosis requires pain and tenderness in the proximal lateral forearm, distal to the lateral epicondyle which may or may not be accompanied by paresthesias depending on the location of the neurological compression.” — p. 156

Confirmatory Diagnosis

Any one of the following

  • Confirmatory electrodiagnostic testing consistent with radial neuropathy, generally including segmental analysis

    “● confirmatory electrodiagnostic testing interpreted as consistent with radial neuropathy that generally includes segmental analysis, aka “inching technique; or” — p. 156

  • OR

    Injection into the radial tunnel with near or total resolution of pain with the anaesthetic

    “● injection into the radial tunnel along the nerve with near/total resolution of pain with the anesthetic, and/or” — p. 156

  • OR

    Wrist and/or digital extensor muscle weakness and/or atrophy

    “● wrist and/or digital extensor muscles weakness and/or atrophy.” — p. 156

Conservative Care

Required

  • Non-operative treatment including elbow and wrist splinting

    “Non-operative treatments include: ● elbow and wrist splinting.” — p. 156

Surgical Considerations (surgical release)

Required

  • Severe symptoms and signs, or lack of improvement after nonoperative treatment trialed for at least 3 months

    “Surgical considerations include either: ● severe symptoms and signs (e.g., severe electrodiagnostic findings, continuous paresthesias, extensor muscle atrophy) or ● lack of improvement or resolution following nonoperative treatment trialed for at least 3 months.” — p. 156

    Any one of the following:

    • Severe symptoms and signs (e.g., severe electrodiagnostic findings, continuous paresthesias, extensor muscle atrophy)

      “● severe symptoms and signs (e.g., severe electrodiagnostic findings, continuous paresthesias, extensor muscle atrophy) or” — p. 156

    • OR

      Lack of improvement or resolution following nonoperative treatment trialed for at least 3 months — at least 3 months

      “● lack of improvement or resolution following nonoperative treatment trialed for at least 3 months.” — p. 156

Procedures — the guideline treats each separately

Surgical release for subacute or chronic radial neuropathy

Recommended.

Strength of Evidence — Recommended, Insufficient Evidence (I)

The guideline offers two alternative routes to surgery: severe symptoms and signs, OR three months without improvement on non-operative treatment. A patient with extensor atrophy or severe electrodiagnostic findings does not have to wait out the three months. Note the Rationale is more cautious than the indication, asking for 3 to 6 months and unequivocal evidence, so a reviewer may quote the longer figure — document the electrodiagnostic findings and the objective loss of function.

Reviewing this for COA, or think a criterion is wrong?