Utilization Review Checklist
Crush Injury and Compartment Syndrome of the Hand, Wrist or Forearm
Derived from the ACOEM Hand, Wrist and Forearm Disorders Guideline, edition 14 July 2025, as adopted into the California MTUS 2 January 2026. CPT 25020, 25023, 26037. ICD-10 T79.6, S67.2.
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
Acute or subacute crush injury or compartment syndrome, with compartment pressures where measured
“Surgery is recommended for treatment of acute or subacute crush injuries or compartment syndrome depending on the nature of the injury.” — p. 163
Surgical Considerations (fasciotomy and associated procedures)
All of the following
Emergency fasciotomy for release of tension, and any procedures addressing fractures or other remediable defects
“This frequently includes emergency fasciotomy for release of tension from compartment syndromes as well as other surgical procedures to address fractures and other remediable defects.” — p. 163
AND
Urgency of the intervention
“Compartment pressure measurements are helpful and assist in guiding need of emergent surgery.” — p. 163
Procedures — the guideline treats each separately
Surgery for acute or subacute crush injury or compartment syndrome
Recommended.
Strength of Evidence — Recommended, Insufficient Evidence (I)
This is frequently an emergency, and the guideline says so: it names EMERGENCY FASCIOTOMY for release of tension from compartment syndrome. Compartment pressure measurements are described as helpful in guiding the need for emergent surgery — record them if taken. Nothing here requires a conservative trial.