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

Ulnar Nerve Entrapment at the Elbow

Derived from the ACOEM Elbow Disorders Guideline, edition 14 July 2025, as adopted into the California MTUS 2 January 2026. CPT 64718, 24495, 64719. ICD-10 G56.2.

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

All of the following

  • Tingling and/or numbness in an ulnar nerve distribution

    “● tingling and/or numbness in an ulnar nerve distribution (i.e., small digit, typically the ulnar aspect of the ring finger and the ulnar border of the hand) and” — p. 177

  • AND

    Symptoms provoked either nocturnally or with sustained elbow flexion

    “● symptoms that are provoked either nocturnally or with sustained elbow flexion.” — p. 177

Confirmatory Diagnosis

Any one of the following

  • Electrodiagnostic testing consistent with ulnar neuropathy at the elbow

    “● electrodiagnostic testing consistent with ulnar neuropathy at the elbow, ideally including segmental analysis/inching technique which should be done to identify the affected ulnar nerve segment” — p. 177

  • OR

    Weakness or atrophy in the ulnar nerve innervated muscles

    “● weakness or atrophy in the ulnar nerve innervated muscles.” — p. 177

Procedures — the guideline treats each separately

Simple (“in situ”) decompression

Recommended. Surgical considerations for in-situ decompression/release are either:

Strength of Evidence — Recommended, Evidence (C) · p. 177

Indications — required:

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

    “Surgical considerations for in-situ decompression/release are either: ● severe symptoms and signs (e.g., severe electrodiagnostic findings, continuous paresthesias, weakness or ulnar nerve-innervated muscle atrophy, and including acute compression due to trauma such as fracture, or ● lack of improvement or resolution following both non-operative treatments above (elbow and wrist splinting) trialed for at least 3 months.” — p. 177

    Any one of the following:

    • Severe symptoms and signs (e.g., severe electrodiagnostic findings, continuous paresthesias, weakness or ulnar nerve-innervated muscle atrophy), including acute compression due to trauma

      “● severe symptoms and signs (e.g., severe electrodiagnostic findings, continuous paresthesias, weakness or ulnar nerve-innervated muscle atrophy, and including acute compression due to trauma such as fracture, or” — p. 177

    • OR

      Lack of improvement or resolution following non-operative treatments trialed for at least 3 months — at least 3 months

      “● lack of improvement or resolution following both non-operative treatments above (elbow and wrist splinting) trialed for at least 3 months.” — p. 177

This is the strongest-graded of the three procedures in this section — Evidence (C) against Insufficient (I) for subcutaneous transposition — and the guideline says plainly that a simple decompression is generally preferred for true cubital tunnel syndrome. If in-situ decompression is what you intend, say so; it is the easiest of the three to get authorised.

Anterior subcutaneous transposition, medial epicondylectomy

Recommended. Anterior subcutaneous transposition, medial epicondylectomy is recommended for patients who fail non-operative treatment for subacute or chronic ulnar neuropathies or patients who have emergent or urgent indications (e.g., acute compression due to fracture, arthritides or compartment syndrome with unrelenting symptoms of nerve impairment).

Strength of Evidence — Recommended, Insufficient Evidence (I) · p. 179

Indications — required:

  • Surgical considerations for ulnar nerve transposition

    “Surgical considerations for ulnar nerve transposition include one of the following:” — p. 177

    Any one of the following:

    • Nerve conduction study localisation by segmental analysis to the condylar groove segment plus severe symptoms and signs

      “● nerve conduction study localization by segmental analysis to the condylar groove segment plus severe symptoms and signs (e.g., severe EDS, continuous tingling/numbness, hypothenar atrophy) including compression due to penetrating trauma, or” — p. 177

    • OR

      Delayed ulnar nerve conduction velocity without localisation, plus evidence of ulnar nerve subluxation at the elbow, plus severe symptoms and signs

      “● nerve conduction study showing delayed ulnar nerve conduction velocity without localization to the affected ulnar nerve segment plus evidence of ulnar nerve subluxation at the elbow plus severe symptoms and signs (e.g., severe EDS, continuous tingling/numbness, hypothenar atrophy), or” — p. 178

    • OR

      Lack of improvement or resolution after at least 3 months after in-situ decompression/local release without transposition — at least 3 months

      “● lack of improvement or resolution after at least 3 months after in-situ decompression/local release without transposition.” — p. 178

Recommended, but on Insufficient (I) evidence and against a guideline that prefers simple decompression. Transposition has its OWN surgical considerations, which are stricter than those for decompression: nerve conduction localisation to the condylar groove, or a delayed conduction velocity plus documented subluxation, or failure at least three months after a previous in-situ decompression. Address whichever applies explicitly, and say why decompression alone is not appropriate.

Anterior submuscular transposition

Not Recommended. Anterior submuscular transposition is not recommended for the treatment of subacute or chronic ulnar neuropathies.

Strength of Evidence — Not Recommended, Insufficient Evidence (I) · p. 181

Indications — required:

  • Anterior submuscular transposition requested

    “Anterior submuscular transposition is not recommended for the treatment of subacute or chronic ulnar neuropathies.” — p. 181

The guideline does NOT recommend anterior submuscular transposition for subacute or chronic ulnar neuropathies. A request will very likely be denied however well documented, and no further documentation changes the recommendation. The supported routes are simple in-situ decompression, which the guideline prefers, or anterior subcutaneous transposition where its own criteria are met.

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