CG-SURG-112 Carpal Tunnel Decompression Surgery

This policy addresses carpal tunnel decompression surgery (open or endoscopic). It is medically necessary when carpal tunnel syndrome is confirmed by clinical assessment and/or electrodiagnostic testing, and symptoms are severe—either persistent pain/sensory loss/paresthesia in the median nerve distribution refractory to conservative therapy (e.g., at least 6 weeks of splinting or local steroid injection) or progressive symptoms with electrodiagnostic evidence of denervation/axonal loss. Surgery is not covered when these criteria are not met, and the following are not medically necessary when performed with carpal tunnel release: skin nerve preservation, epineurotomy, and flexor retinaculum lengthening.

"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:"