Utilization Review Checklist
Ankle Tenosynovitis (including stenosing tenosynovitis)
Derived from the ACOEM Ankle and Foot Disorders Guideline, edition 29 January 2026, as adopted into the California MTUS 1 August 2026. CPT 27680, 27681. ICD-10 M65.87.
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
Conservative Care
Required
Failure of non-operative interventions generally including at least 2 glucocorticosteroid injections, or a clear contraindication
“Indications Ankle tenosynovitis that fails to respond to non-operative interventions generally including at least 2 glucocorticosteroid injections. May be indicated without prior injection(s) if there is a clear contraindication for injections.” — p. 333
Surgical Considerations (surgical release)
Required
Release requested for subacute or chronic tenosynovitis failing to respond to injection
“There is no recommendation for or against the use of surgical release for patients with subacute or chronic ankle tenosynovitis who fail to respond to injection” — p. 333
Procedures — the guideline treats each separately
Surgical release for subacute or chronic ankle tenosynovitis
No Recommendation.
Strength of Evidence — No Recommendation, Insufficient Evidence (I) · confidence low
ACOEM gives NO recommendation for or against release here — there are no quality studies. That is neutrality rather than refusal, and the guideline still publishes indications, so the case rests on meeting them: failure of non-operative treatment generally including at least TWO glucocorticosteroid injections, or a clear documented contraindication to injecting. Note separately that the guideline says tendinous ruptures are often surgically treated — if the tendon is ruptured, that is a different conversation.