Utilization Review Checklist
Dupuytren's Disease and Contracture
Derived from the ACOEM Hand, Wrist and Forearm Disorders Guideline, edition 14 July 2025, as adopted into the California MTUS 2 January 2026. CPT 26123, 26121, 26125. ICD-10 M72.0.
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
Confirmatory Diagnosis
Required
Contracture due to Dupuytren's disease
“Surgery using the technique of regional or selective fasciectomy is recommended for contracture due to Dupuytren's disease.” — p. 169
Procedures — the guideline treats each separately
Regional or selective fasciectomy
Recommended. Surgery using the technique of regional or selective fasciectomy is recommended for contracture due to Dupuytren's disease.
Strength of Evidence — Recommended, Insufficient Evidence (I) · confidence low · p. 169
Indications — required:
Functional limitations due to the contracture
“thus, surgery is recommended particularly for patients with functional limitations.” — p. 169
This is the ONLY surgical technique the guideline recommends for Dupuytren's contracture. Four others in the same section are not recommended. Name regional or selective fasciectomy explicitly — a request that says only 'Dupuytren's surgery' risks being read against one of the four declined techniques. The guideline supports it particularly for patients with functional limitations, so document those.
Percutaneous needle fasciotomy (needle aponeurotomy)
Not Recommended. Percutaneous needle fasciotomy (needle aponeurotomy) is not recommended for patients with contractures due to Dupuytren's disease due to the high recurrence rates common with this technique.
Strength of Evidence — Not Recommended, Insufficient Evidence (I) · confidence low · p. 170
Indications — required:
Percutaneous needle fasciotomy (needle aponeurotomy) requested
“Percutaneous needle fasciotomy (needle aponeurotomy) is not recommended for patients with contractures due to Dupuytren's disease due to the high recurrence rates common with this technique.” — p. 170
Not recommended, on the stated ground of high recurrence rates. Request regional or selective fasciectomy instead — that is the technique the guideline supports.
Extensive fasciectomy
Not Recommended. Extensive fasciectomy is not recommended for routine Dupuytren's contracture surgery.
Strength of Evidence — Not Recommended, Evidence (C) · confidence low · p. 171
Indications — required:
Extensive fasciectomy requested
“Extensive fasciectomy is not recommended for routine Dupuytren's contracture surgery.” — p. 171
Not recommended for routine Dupuytren's contracture surgery, on (C) evidence. The recommended technique is the more limited regional or selective fasciectomy.
Dermofasciectomy
Not Recommended. Dermofasciectomy is not recommended for routine Dupuytren's contracture surgery.
Strength of Evidence — Not Recommended, Evidence (C) · confidence low · p. 172
Indications — required:
Dermofasciectomy requested
“Dermofasciectomy is not recommended for routine Dupuytren's contracture surgery.” — p. 172
Not recommended for routine Dupuytren's contracture surgery, on (C) evidence. Request regional or selective fasciectomy instead.
“Firebreak” full-thickness skin graft
Not Recommended. “Firebreak” full-thickness skin graft is not recommended for routine Dupuytren's contracture surgery.
Strength of Evidence — Not Recommended, Evidence (C) · confidence low · p. 171
Indications — required:
“Firebreak” full-thickness skin graft requested
““Firebreak” full-thickness skin graft is not recommended for routine Dupuytren's contracture surgery.” — p. 171
Not recommended for routine Dupuytren's contracture surgery. The guideline states full-thickness skin graft has been found to be ineffective.