Utilization Review Checklist
Shoulder Dislocation and Instability
Derived from the ACOEM Shoulder Disorders Guideline, edition 14 July 2025, as adopted into the California MTUS 2 January 2026. CPT 23455, 23462, 29806. ICD-10 S43.0, M24.41.
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
Required
Shoulder dislocation or instability, including after a first traumatic dislocation
“Shoulder dislocation or instability, including after a first traumatic dislocation. There is no requirement to have rehabilitation prior to surgery if there is a dislocation which has occurred as a consequence of an acute injury. Instability with recurrent dislocations due to congenital laxity may reasonably be rehabilitated first, prior to consideration of surgery.” — p. 460
Conservative Care
Any one of the following
Dislocation occurring as a consequence of an acute injury — no requirement to have rehabilitation prior to surgery
“There is no requirement to have rehabilitation prior to surgery if there is a dislocation which has occurred as a consequence of an acute injury.” — p. 460
OR
Recurrent dislocations due to congenital laxity, rehabilitated first
“Instability with recurrent dislocations due to congenital laxity may reasonably be rehabilitated first, prior to consideration of surgery.” — p. 460
Procedures — the guideline treats each separately
Arthroscopic surgery for shoulder dislocation and instability
Recommended. Arthroscopy or open surgery is recommended for evaluation and treatment of patients with dislocation and instability.
Strength of Evidence — Recommended, Insufficient Evidence (I) · confidence high · p. 460
Indications — required:
Arthroscopic stabilisation requested
“Arthroscopy or open surgery is recommended for evaluation and treatment of patients with dislocation and instability.” — p. 460
Note the HIGH level of confidence — unusual for an Insufficient (I) grade and strong ground to stand on. The most useful sentence in this section is that there is NO requirement to have rehabilitation before surgery where the dislocation followed an acute injury. If a reviewer demands a course of therapy first for a traumatic dislocation, that requirement is not in the adopted guideline — quote it. The guideline also says surgery after a FIRST dislocation is reasonable.
Open surgery for shoulder dislocation and instability
Recommended. Open surgery or arthroscopy is recommended for evaluation and treatment of patients with dislocation and instability.
Strength of Evidence — Recommended, Insufficient Evidence (I) · confidence high · p. 462
Indications — required:
Open stabilisation requested
“Open surgery or arthroscopy is recommended for evaluation and treatment of patients with dislocation and instability.” — p. 462
Same indications and same High confidence as the arthroscopic route — the guideline recommends them in the same breath and states there is insufficient evidence to recommend for or against specific intraoperative techniques. It does record that open Bankart repair has somewhat lower recurrence and reoperation rates while arthroscopic gives better range of motion, so the choice is yours to make and is not a ground for denial.
Inferior capsular shift, capsular plication, or superior shift of redundant inferior capsule for multidirectional or posterior instability
Recommended. Inferior capsular shift procedure, capsular plication, or superior shift of redundant inferior capsule is recommended for multidirectional and posterior instability.
Strength of Evidence — Recommended, Insufficient Evidence (I) · confidence moderate · p. 463
Indications — required:
Recurrent, multidirectional shoulder instability or dislocation
“Recurrent, multidirectional shoulder instability or dislocation.” — p. 463
A separate recommendation with its own, shorter indication: recurrent, multidirectional shoulder instability or dislocation. Say the instability is multidirectional or posterior and that it is recurrent — those two words are the criterion. The guideline notes there is no other reasonable alternative for some of these patients, which is worth quoting.