Utilization Review Checklist
Distal Radius Fracture
Derived from the ACOEM Hand, Wrist and Forearm Disorders Guideline, edition 14 July 2025, as adopted into the California MTUS 2 January 2026. CPT 25607, 25608, 25609, 25605. ICD-10 S52.5.
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
Distal radius fracture, with displacement and stability described
“Open reduction and internal fixation by either dorsal or volar plating is recommended if fracture remains unstable by other treatment methods.” — p. 212
Conservative Care
Required
Fracture remains unstable by other treatment methods
“Open reduction and internal fixation by either dorsal or volar plating is recommended if fracture remains unstable by other treatment methods.” — p. 212
Surgical Considerations (ORIF by dorsal or volar plating)
Required
Dorsal or volar plating, no preferential approach
“Open reduction and internal fixation by either dorsal or volar plating is recommended if fracture remains unstable by other treatment methods. There is no clear evidence of a preferential approach.” — p. 212
Procedures — the guideline treats each separately
Open reduction and internal fixation via dorsal or volar plating
Recommended.
Strength of Evidence — Recommended, Insufficient Evidence (I) · confidence low
The criterion is instability that persists after other treatment methods — so the note has to show what was tried and that the fracture remained unstable, not merely that it was displaced at presentation. The guideline states there is no clear evidence of a preferential approach between dorsal and volar plating, so the approach is not a ground for denial.