Utilization Review Checklist
Thoracic Outlet Syndrome
Derived from the ACOEM Shoulder Disorders Guideline, edition 14 July 2025, as adopted into the California MTUS 2 January 2026. CPT 21700, 21705, 21615. ICD-10 G54.0.
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
Clearly identifiable and significantly symptomatic anatomical abnormality, including cervical ribs or other constrictive structures
“Indications Clearly identifiable and significantly symptomatic anatomical abnormality, including cervical ribs and other constrictive anatomic structure(s).” — p. 414
AND
Functional impairments
“Candidates for surgery should also have functional impairments.” — p. 414
Conservative Care
Any one of the following
A minimum of 3 months of progressive, active exercises prescribed and failed — at least 3 months
“A minimum of 3 months of progressive, active exercises should be prescribed and failed.” — p. 414
OR
Arterial thoracic outlet syndrome, which generally needs earlier surgical intervention
“Arterial TOS generally needs earlier surgical intervention.” — p. 414
Surgical Considerations (surgery for thoracic outlet syndrome)
Required
Surgery requested, addressing the identified constrictive structure
“Surgery is recommended for treatment of thoracic outlet syndrome.” — p. 414
Procedures — the guideline treats each separately
Surgery for thoracic outlet syndrome
Recommended.
Strength of Evidence — Recommended, Insufficient Evidence (I) · confidence low
The gate here is anatomical: a CLEARLY IDENTIFIABLE and significantly symptomatic anatomical abnormality, such as a cervical rib or other constrictive structure. Symptoms alone do not meet it. Three months of progressive active exercises must also have been prescribed and failed — except in ARTERIAL TOS, which the guideline says generally needs earlier surgical intervention.