Treatments/ Procedures

PerForm Utilization Review Builder

Treatment UR Form

  1. Tx   Carpal Tunnel Release Surgery (CTR)


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Treatment UR Form


If any of the indications below are present, refer to Peer for Review
Pregnancy Untreated inflammatory arthritis of the wrist Untreated diabetes Thyroid disease Pernicious Anemia Patients with a known space-occupying lesion in the carpal tunnel Failed treatment after surgery Cervical Radiculopathy Flexor carpi radialis tenosynovitis Volar radial ganglion Multiple sclerosis Brachial plexus injury Cervical syringomyelia Neuralgic amyotrophy
Mild CTS: Intermittent numbness, tingling, wrist pain at night or with repetitive use or sustained griping. No motor/sensory deficit. Symptoms disappear with conservative treatment or underlying disorder corrected or with modification of activity. Benefit from conservative treatment. Patients who have mild, occasional symptoms are not necessarily treated. Many mild carpal tunnel syndrome sufferers either change their hand use pattern or posture at work or find a conservative, non-surgical treatment that allows them to return to full activity without hand numbness/pain and sleep disruption. Moderate CTS: Frequent symptoms. Signs of median nerve irritability. Mild sensory loss, but no motor weakness or may have mild motor deficit. NCS abnormal. Good chance of responding to surgical decompression. Severe CTS: Continuous symptoms. Sensory and motor deficit. Median nerve sensory & motor conduction abnormal. Denervation on EMG. Muscle atrophy: severe weakness of thenar muscles. Two-point discrimination over 6 mm. Early referral for surgical decompression.
*The Median Nerve distribution is over the palm in the first three and a half fingers (the thumb, index finger, middle finger, and the first half of the ring finger (the radial half, meaning the half closest to the thumb) *Paresthesia is numbness, tingling, and/or burning.
1. Is the CTS related to a trauma, such as a distal radius fracture?
radio Is CTS acute (sudden onset after the fracture) radio Is CTS chronic
Is CTS Moderate/Severe)
Was diagnosis of Moderate/Severe CTS confirmed by history, physical examination and possible electrodiagnostic studies; if no, then continue on to main questions (#2 and on)) (if Yes, then no need to ask any additional questions, approve,
No - continue to main questions #2
2. Are the symptoms intermittent or constant? a. Intermittent b. Frequent c. Constant
3. Is there muscle atrophy/thenar atrophy (loss of muscle mass/severe weakness of the thenar muscles). This is typically documented as weakness of the thumb-thumb abduction, weakness of the thenar muscles, or weakness of the Abductor pollicis brevis (APB) (<=-4/5). This may also be documented as the patient not being able to or having difficulty with placing the affected thumb perpendicular to the palm, frequently dropping, objects, not being able to hold a pen/pencil, etc. Yes (if #2=c and #3/#4/#5/#6 yes, then approve) No
4. Is 2-point discrimination test >6mm (in severe carpal tunnel syndrome, the patient will not be able to tell the difference between the two touches if done less than 6mm apart, and will feel like they were touched in the same place). Yes (if yes, then treat #2 as C) No
5. Has there been any electrodiagnostic studies done (Electromyography (EMG) and/or Nerve conduction velocity (NCV) ) Yes No (if no, send to peer review, regardless of other answers)
6. If EMG/NCV studies have been performed, do the studies reveal median nerve entrapment? (if the studies also reveal evidence of non-classic median nerve findings (e.g. cervical radicular, ulnar nerve, peripheral neuropathy, etc. send to peer review). Yes No
7. Is there a positive Tinel’s sign (pain/tingling/numbness over the palm and into the first three fingers when tapping over the inside of the wrist). This is typically documented as the patient having a positive Tinel’s at the right and/or left. It can also be documented as distal tingling on percussion (DTP). Yes No
8. Is there documentation of a positive Phalen’s sign/Wrist Flexion Test (is there evidence of paresthesia (burning, tingling, numbness) in the distribution of the median nerve (the palm side of the hand, in the first three and a half fingers (thumb, index, middle, and ½ the ring finger) when the wrist is held for a minute in flexion)? This can be documented as a positive Phalen’s sign, a positive reverse Phalen’s sign, and/or a positive Modified Phalen’s Test (all are variations of the Phalen’s maneuver used to detect compression over the carpal tunnel) Yes No
9. Is there evidence of impaired dexterity (could be documented as difficulty with finger movements, fine motor movements, difficulty folding clothes, holding objects, writing/drawing, zipping or buttoning clothes, etc.) ? a. Yes b. No
10. Is there any paresthesia’s (numbness/tingling) in the affected hand or any wrist pain at night (could be documented as pain/paresthesia’s that wake the patient at night, or interfere with sleep)? a. Yes b. No
11. Is there documentation of a “Classic” or “Probable” pattern on the Katz Hand diagram or a score of 2 or 3? Yes No
12. Is there a Positive Flick Sign (waking at night with paresthesia’s, and shaking the effected hand(s) to try and obtain some relief). Yes (yes to #9 and two of 10-12) No
13. Is there a Positive Durkan’s Test/Carpal Tunnel Compression Test (paresthesia’s within 30 seconds following compression over the carpal tunnel). Yes No
14. Is there a positive Semmes-Weinstein monofilament test Yes No
15. Has the patient received activity modifications for a month or more? Yes No
16. Has the patient used a wrist splint at night for a month or more? Yes No
17. Has the patient trialed any NSAIDs, Acetaminophen, or any non-prescription pain medications? Yes No
18. Has the patient been instructed and performing an independent home exercise and stretching program? Yes No
19. Has the patient had a corticosteroid injection? Yes (if yes, ask if there was a positive response) No

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