25999
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Key Coverage Criteria
- Carpal tunnel decompression surgery (open or endoscopic) is consideredmedically necessarywhen the criteria in Section I (Diagnostic criteria)andSection II (Symptom Severity criteria) below are met:
- Diagnostic Criteria:Clinical evaluation confirms the diagnosis of carpal tunnel syndrome by a consistent history, physical exam and/or confirmatory electrodiagnostic testing.and
- Degree of Clinical Severity Criteria:The symptoms are severe based on one (1) or more of the following: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:6 weeks of hand/wrist immobilization (brace or splint);orLocal steroid injections;orThere is progressive pain, sensory loss, or paresthesia in the median nerve distribution with evidence of median nerve denervation or [...]
- 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:6 weeks of hand/wrist immobilization (brace or splint);orLocal steroid injections;or
- 6 weeks of hand/wrist immobilization (brace or splint);or
- Local steroid injections;or
1 Active Policy
ANTHEM-CG-SURG-112 — CG-SURG-112 Carpal Tunnel Decompression Surgery
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