Utilization Review Checklist
Tarsal-Metatarsal (Lisfranc) Injury
Derived from the ACOEM Ankle and Foot Disorders Guideline, edition 29 January 2026, as adopted into the California MTUS 1 August 2026. CPT 28615, 28606. ICD-10 S93.3, S92.3.
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
Fracture joint displacement with joint dislocation greater than 2 mm
“Indications Fracture joint displacement with joint dislocation >2 mm (Myerson, 1999).” — p. 229
Surgical Considerations (operative management)
Required
Fixation with K-wire or screws, or primary arthrodesis, with non-weight bearing for 6 to 12 weeks
“Frequency/Dose/Duration Operative fixation with K-wire or screws, or primary arthrodesis; non-weight bearing for 6 to 12 weeks and edema management” — p. 229
Procedures — the guideline treats each separately
Operative management for an unstable tarsal-metatarsal injury
Recommended.
Strength of Evidence — Recommended, Insufficient Evidence (I) · confidence moderate
A numeric criterion, which is rare and helpful: fracture joint displacement with joint dislocation GREATER THAN 2 mm. Measure it and quote it. The guideline also sets out the aftercare it expects — K-wire or screw fixation or primary arthrodesis, then non-weight bearing for 6 to 12 weeks — so including the plan pre-empts questions.