Utilization Review Checklist
Kienböck Disease
Derived from the ACOEM Hand, Wrist and Forearm Disorders Guideline, edition 14 July 2025, as adopted into the California MTUS 2 January 2026. CPT 25443, 25651, 25390. ICD-10 M93.1.
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
Moderate to marked impairment due to Kienböck disease
“Surgical treatment is recommended as an option for patients with moderate to marked impairment if not improved 8 weeks post-injury or after 6 weeks of non-operative treatment due to Kienbock disease.” — p. 347
Conservative Care
Any one of the following
Not improved 8 weeks post-injury — at least 8 weeks
“if not improved 8 weeks post-injury” — p. 347
OR
Not improved after 6 weeks of non-operative treatment — at least 6 weeks
“or after 6 weeks of non-operative treatment due to Kienbock disease.” — p. 347
Surgical Considerations (surgical treatment)
Required
Surgical treatment requested as an option
“Surgical treatment is recommended as an option for patients with moderate to marked impairment” — p. 347
Procedures — the guideline treats each separately
Surgical treatment for chronic Kienböck disease
Recommended.
Strength of Evidence — Recommended, Insufficient Evidence (I) · confidence moderate
Two alternative clocks, and they are short: not improved by 8 WEEKS POST-INJURY, or after 6 WEEKS of non-operative treatment. Either satisfies it. The patient must also have moderate to marked impairment — document that with measured range of motion and grip strength.