Utilization Review Checklist
Carpal Tunnel Syndrome
Derived from the ACOEM Hand, Wrist and Forearm Disorders Guideline, edition 14 July 2025, as adopted into the California MTUS 2 January 2026. CPT 64721, 29848. ICD-10 G56.0.
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
Presumptive Diagnosis
All of the following
Paresthesias in at least two median-nerve served digits
“Paresthesias in at least two median-nerve served digits and symptoms that are either nocturnal or on provocative testing.” — p. 119
AND
Symptoms that are either nocturnal or on provocative testing
“symptoms that are either nocturnal or on provocative testing” — p. 119
Confirmatory Diagnosis
Any one of the following
Confirmatory electrodiagnostic study interpreted as consistent with median mononeuropathy
“a confirmatory electrodiagnostic study interpreted as consistent with median mononeuropathy” — p. 119
OR
Symptom improvement or resolution with glucocorticosteroid injection
“OR symptom improvement or resolution with glucocorticosteroid injection.” — p. 119
Conservative Care
Required
Failure of at least two nonoperative treatments
“Patients should have failure of at least two nonoperative treatments (i.e., nocturnal wrist splinting, physical activity modifications if high exposure(s), glucocorticosteroid injection, oral glucocorticosteroids, phonophoresis).” — p. 119
At least 2 of the following:
Nocturnal wrist splinting
“Patients should have failure of at least two nonoperative treatments (i.e., nocturnal wrist splinting, physical activity modifications if high exposure(s), glucocorticosteroid injection, oral glucocorticosteroids, phonophoresis).” — p. 119
OR
Physical activity modifications if high exposure(s)
“Patients should have failure of at least two nonoperative treatments (i.e., nocturnal wrist splinting, physical activity modifications if high exposure(s), glucocorticosteroid injection, oral glucocorticosteroids, phonophoresis).” — p. 119
OR
Glucocorticosteroid injection
“Patients should have failure of at least two nonoperative treatments (i.e., nocturnal wrist splinting, physical activity modifications if high exposure(s), glucocorticosteroid injection, oral glucocorticosteroids, phonophoresis).” — p. 119
OR
Oral glucocorticosteroids
“Patients should have failure of at least two nonoperative treatments (i.e., nocturnal wrist splinting, physical activity modifications if high exposure(s), glucocorticosteroid injection, oral glucocorticosteroids, phonophoresis).” — p. 119
OR
Phonophoresis
“Patients should have failure of at least two nonoperative treatments (i.e., nocturnal wrist splinting, physical activity modifications if high exposure(s), glucocorticosteroid injection, oral glucocorticosteroids, phonophoresis).” — p. 119
Surgical Considerations (carpal tunnel release)
Any one of the following
Failure of nonoperative treatment for subacute or chronic CTS
“Surgical release is strongly recommended for patients who fail nonoperative treatment for subacute or chronic CTS” — p. 119
Required:
Carpal tunnel release requested after failed nonoperative treatment
“Surgical release is strongly recommended for patients who fail nonoperative treatment for subacute or chronic CTS” — p. 119
OR
Severe symptoms such as continuous tingling and numbness in a median nerve distribution
“Surgical release is also indicated for severe symptoms such as continuous tingling and numbness in a median nerve distribution.” — p. 119
Required:
Severe symptoms such as continuous tingling and numbness in a median nerve distribution
“Surgical release is also indicated for severe symptoms such as continuous tingling and numbness in a median nerve distribution.” — p. 119
OR
Re-operation indications
“Re-operation is potentially indicated if:” — p. 120
Any one of the following:
Prolonged period of symptom improvement (>12 months) after surgical release and then symptoms recurred — at least 12 months
“● there was a prolonged period of symptom improvement (>12 months) after surgical release and then symptoms recurred, or there is” — p. 120
OR
Clinical evidence of an incomplete release
“● clinical evidence of an incomplete release.” — p. 120
Procedures — the guideline treats each separately
Surgical release for subacute or chronic carpal tunnel syndrome
Strongly Recommended.
Strength of Evidence — Strongly Recommended, Evidence (A) · confidence high
The strongest grade in this chapter — Strongly Recommended on (A) evidence, high confidence. A denial against a note documenting the paresthesias, the two failed non-operative treatments and either a confirmatory study or a response to injection is worth appealing. Severe continuous symptoms are an independent indication that does not wait on the non-operative trial.