Utilization Review Checklist
Acromioclavicular Sprains and Dislocations
Derived from the ACOEM Shoulder Disorders Guideline, edition 14 July 2025, as adopted into the California MTUS 2 January 2026. CPT 23550, 23552, 29824. ICD-10 S43.5, S43.1.
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
All of the following
X-rays obtained for evaluation of the AC joint
“X-rays are recommended for evaluation of the AC joint.” — p. 504
AND
Separation graded on the I to VI scale, with Grade III defined by elevation of the distal clavicle of at least 1 clavicular diameter on AP radiograph
“The most commonly used scale grades AC sprains and dislocations from I to VI (2064,2065,2066). Grades I and II are managed non-operatively. Grade III includes severe dislocation of the AC joint with elevation of the distal clavicle of at least 1 clavicular diameter on AP radiograph. Grades IV to VI are believed to require surgery” — p. 504
Procedures — the guideline treats each separately
Arthroscopic or minimally invasive repair for Grade III-V separations
Recommended. Arthroscopic or minimally invasive surgical techniques are recommended for acromioclavicular joint separations.
Strength of Evidence — Recommended, Evidence (C) · confidence low · p. 530
Indications — required:
Grade III-V AC separation thought to need surgical repair
“Grade III-V AC separations thought to need surgical repair.” — p. 530
The best-graded surgical option in this section — Recommended on (C) evidence. Its stated indication is short: Grade III-V separations thought to need surgical repair. If the separation is Grade IV to VI, the guideline's own diagnostic criteria say those grades are believed to require surgery, which is the strongest footing available here.
Surgical repair of a Grade III separation in highly select patients
Recommended. Surgical repair is recommended for highly select patients with Grade III acromioclavicular joint separations.
Strength of Evidence — Recommended, Insufficient Evidence (I) · confidence low · p. 527
Indications — all of the following:
Symptomatic Grade III acromioclavicular joint separation
“Symptomatic Grade III acromioclavicular joint separation in patients with concerns about cosmesis, or those with unusually high physical occupational or sports demands” — p. 527
AND
Concerns about cosmesis, or unusually high physical occupational or sports demands
“in patients with concerns about cosmesis, or those with unusually high physical occupational or sports demands” — p. 527
Any one of the following:
Concerns about cosmesis
“in patients with concerns about cosmesis,” — p. 527
OR
Unusually high physical occupational or sports demands
“or those with unusually high physical occupational or sports demands,” — p. 527
Grade III is the contested grade. Routine repair of it is Moderately Not Recommended on (B) evidence, but repair in HIGHLY SELECT patients is recommended — the qualifier is what carries the request. Document concerns about cosmesis or unusually high physical occupational or sports demands, and say the symptoms are not trending towards resolution. A Grade III request that does not name the selecting factor will be read against the routine-repair recommendation and refused.
Routine surgical repair of a Grade III separation
Moderately Not Recommended. Routine surgical repair is moderately not recommended for Grade III acromioclavicular joint separations
Strength of Evidence — Moderately Not Recommended, Evidence (B) · confidence moderate · p. 526
Indications — required:
Routine surgical repair requested for a Grade III separation
“Routine surgical repair is moderately not recommended for Grade III acromioclavicular joint separations” — p. 526
The guideline moderately does NOT recommend routine repair of Grade III separations, on (B) evidence — multiple moderate-quality trials reporting equivalent clinical results with higher complications in the operated group. Do not file this as a routine repair. If your patient has cosmesis concerns or unusually high physical demands, the guideline has a separate recommendation that DOES support surgery — request under that instead and say which factor applies.
Surgical grafting for acromioclavicular joint separation
No Recommendation. There is no recommendation for or against surgical grafting for acromioclavicular joint separations.
Strength of Evidence — No Recommendation, Insufficient Evidence (I) · confidence low · p. 526
Indications — required:
Surgical grafting requested
“There is no recommendation for or against surgical grafting for acromioclavicular joint separations.” — p. 526
ACOEM gives NO RECOMMENDATION for or against surgical grafting — two small studies, one possibly with a randomisation failure, is too sparse a base to conclude either way. That is not a refusal: the guideline neither supports nor opposes it. Expect the absent recommendation to be raised, and consider whether an arthroscopic or minimally invasive technique, which IS recommended on (C) evidence, addresses the same problem.