Brachial Plexus Injury

Utilization Review Checklist

Derived from the ACOEM Shoulder Disorders Guideline, edition 14 July 2025, as adopted into the California MTUS 2 January 2026. CPT 64713, 64861, 64905. ICD-10 S14.3.

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

Confirmatory Diagnosis

All of the following

Moderate to severe brachial plexus injury
“Indications Moderate to severe brachial plexus injuries, generally with supportive studies including at least electrodiagnostic studies and imaging (e.g., MRI or CT myelography).” — p. 629
AND
Supportive studies including at least electrodiagnostic studies AND imaging (MRI or CT myelography)
“generally with supportive studies including at least electrodiagnostic studies and imaging (e.g., MRI or CT myelography).” — p. 629

Conservative Care

Any one of the following

Clear indication such as a completely severed or torn nerve structure
“Earlier surgery is generally only indicated when there is clear indication(s) such as completely severed/torn nerve structure.” — p. 629
OR
A period of supervised therapy completed without adequate recovery
“Otherwise, a period of supervised therapy wi” — p. 629

Surgical Considerations (surgery for brachial plexus injury)

Required

Surgery requested for a carefully selected patient
“Surgery is selectively recommended for treatment of carefully select patients with brachial plexus injuries.” — p. 629

Procedures — the guideline treats each separately

Surgery for brachial plexus injuries

Recommended.

Strength of Evidence — Recommended, Insufficient Evidence (I) · confidence moderate

Two things carry this request. First, supportive studies: the guideline asks for AT LEAST electrodiagnostic studies AND imaging — MRI or CT myelography — not one or the other. Second, timing: earlier surgery is generally indicated only where there is a clear indication such as a completely severed or torn nerve structure; otherwise a period of supervised therapy is expected first. Say which situation applies.