Utilization Review Checklist
Pectoralis Major Tear or Rupture
Derived from the ACOEM Shoulder Disorders Guideline, edition 14 July 2025, as adopted into the California MTUS 2 January 2026. CPT 23440, 24341. ICD-10 S43.42, M66.11.
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
Complete or nearly complete rupture of the pectoralis major insertion
“Indications Severe pectoralis major strains with complete or nearly complete pectoralis muscle ruptures. Pectoralis minor tears are infrequent, and typically treated non-operatively.” — p. 422
Surgical Considerations (surgical repair)
Required
Repair requested for a complete or nearly complete rupture
“Surgery is recommended for patients with complete or nearly complete tears or ruptures of the pectoralis major insertion” — p. 422
Procedures — the guideline treats each separately
Surgery for complete or nearly complete pectoralis major rupture
Recommended.
Strength of Evidence — Recommended, Insufficient Evidence (I) · confidence high
High confidence, and the criterion is the extent of the tear: complete or NEARLY complete rupture of the pectoralis major insertion. The guideline adds that pectoralis MINOR tears are infrequent and typically treated non-operatively — so name which muscle is torn, because that alone can decide the request.