Anthem Blue Cross Connecticut CG-SURG-112 Carpal Tunnel Decompression Surgery Form

This document addresses open and endoscopic surgical decompression of the median nerve, as a treatment for carpal tunnel syndrome, which occurs when the median nerve, which runs from the forearm into the palm of the hand, becomes compressed or squeezed at the wrist. The carpal tunnel is a narrow, rigid passageway of ligament and bones at the base of the hand that houses the median nerve and the tendons that bend the fingers. The median nerve provides feeling to the palm side of the thumb and to most of the fingers.

Note: For a related topic, see CG-MED-24 Electromyography and Nerve Conduction Studies

Clinical Indications

Medically Necessary:

Carpal tunnel decompression surgery (open or endoscopic) is considered medically necessary when the criteria in Section I (Diagnostic criteria) and Section II (Symptom Severity criteria) below are met:

1. Diagnostic Criteria:
   Clinical evaluation confirms the diagnosis of carpal tunnel syndrome by a consistent history, physical exam and/or confirmatory electrodiagnostic testing.
   and
2. Degree of Clinical Severity Criteria:
   The symptoms are severe based on one (1) or more of the following:
   1. There is persistent pain, sensory loss, or paresthesia in the median nerve distribution that is refractory to one (1) or more of the following noninvasive conservative treatments:
      1. 6 weeks of hand/wrist immobilization (brace or splint); or
      2. Local steroid injections; or
   2. There is progressive pain, sensory loss, or paresthesia in the median nerve distribution with evidence of median nerve denervation or axonal loss confirmed by electrodiagnostic testing.

Not Medically Necessary:

Carpal tunnel decompression surgery (open or endoscopic) is considered not medically necessary when the criteria above have not been met.

The following procedures are all considered not medically necessary when performed with a carpal tunnel release procedure:

1. Skin nerve preservation; or
2. Epineurotomy; or
3. Flexor retinaculum lengthening; or
4. Internal neurolysis; or
5. Hydrodissection.

The following surgical techniques are considered not medically necessary for treating carpal tunnel syndrome:

1. Thread carpal tunnel release (TCTR); or
2. Ultrasound-guided percutaneous needle release (PCTR).