Utilization Review Checklist
Shoulder Fracture (including proximal humerus)
Derived from the ACOEM Shoulder Disorders Guideline, edition 14 July 2025, as adopted into the California MTUS 2 January 2026. CPT 23615, 23616, 23472. ICD-10 S42.2, S42.1.
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
Required
Displaced shoulder fracture, with the pattern and part count described
“Surgical intervention for shoulder fractures is recommended for select patients with displaced fractures.” — p. 561
Procedures — the guideline treats each separately
Surgical treatment for displaced shoulder fractures
Recommended. Surgical intervention for shoulder fractures is recommended for select patients with displaced fractures.
Strength of Evidence — Recommended, Insufficient Evidence (I) · confidence high · p. 561
Indications — required:
Decision based on factors assessed in aggregate by the orthopaedic surgeon, including open fractures, multiple-part fractures and associated vascular injury
“Indications Based on numerous factors assessed and evaluated in aggregate by the orthopedic surgeon, including (but not limited to) the surgeon’s preferences and experiences, open fractures, multiple-part fractures, associated vascular injur” — p. 561
High confidence, and unusually deferential: the guideline says the decision rests on numerous factors assessed in aggregate BY THE ORTHOPAEDIC SURGEON, expressly including the surgeon's own preferences and experience, alongside open fractures, multiple-part fractures and associated vascular injury. That is rare language and worth quoting — but it works only if your note actually sets out the factors you weighed.
Arthroplasty, most commonly hemiarthroplasty, for displaced proximal humeral fractures
Recommended. Arthroplasty, most commonly hemiarthroplasty, is recommended for select patients with displaced proximal humeral fractures.
Strength of Evidence — Recommended, Insufficient Evidence (I) · confidence moderate · p. 563
Indications — required:
Displaced proximal humeral fracture
“Indications Select patients with displaced proximal humeral fractures.” — p. 563
For select patients with DISPLACED PROXIMAL HUMERAL fractures. The guideline names hemiarthroplasty as the most common form and reports superior results compared with other approaches, while noting the potential for worse results than less major surgery.