Is surgical release of the palm/finger tendon (code 26440) medically necessary for a 47-year-old male with trigger finger and carpal tunnel syndrome?

Medical Necessity Assessment for Trigger Finger Release (CPT 26440)

Direct Recommendation

Yes, surgical release of the palm/finger tendon (CPT 26440) is medically necessary for this 47-year-old male with trigger finger of the left middle finger, particularly given the documented failure of conservative management including splinting, NSAIDs, physical therapy, and stretching exercises over approximately 7 months since injury. 1, 2, 3

Clinical Justification

Conservative Treatment Failure Documented

• This patient has undergone an adequate trial of conservative management initiated by his primary care physician, including splinting, NSAIDs, physical therapy, and stretching exercises, all with minimal relief 3, 4
• The 4-6 month threshold for conservative therapy has been exceeded (injury April 2025, evaluation November 2025 = 7 months), meeting standard criteria for surgical intervention 4
• The patient reports persistent inability to fully flex the left middle finger despite these interventions, with pain rated 3/10 and functional impairment affecting activities of daily living, work ability, and sleep 2, 3

Surgical Indications Met

Surgery is indicated when pain persists despite well-managed conservative treatment trials 5

Key clinical features supporting surgical necessity:

• Documented mechanical triggering with inability to fully flex the finger 2
• Morning stiffness and occasional popping sensation consistent with stenosing tenosynovitis 2
• Functional impairment interfering with work (maintenance control at American Airlines) and activities of daily living 3
• Symptoms aggravated by gripping, lifting, and making a fist 2

Surgical Technique

• Open A-1 pulley release is the standard surgical treatment for trigger finger, consisting of release of the first annular pulley 2
• Surgical treatment provides definitive resolution in the vast majority of cases 2, 3
• Complications are rare but include bowstringing, digital nerve injury, and continued triggering 2

Concurrent Carpal Tunnel Syndrome Consideration

Separate but Related Conditions

• The patient reports numbness and tingling in the left middle finger, primarily in the mornings, with nighttime awakening—symptoms consistent with concurrent carpal tunnel syndrome 1, 4
• Surgical decompression is the most effective treatment for carpal tunnel syndrome, providing significantly better symptom relief than non-surgical options, especially for moderate to severe cases 1
• The development of trigger finger after carpal tunnel release occurs in 10-20% of cases, but this patient has both conditions pre-operatively 6, 7

Combined Surgical Approach

• Addressing both conditions simultaneously is reasonable given the documented conservative treatment failure for trigger finger and symptomatic carpal tunnel syndrome 1, 4
• Open carpal tunnel release combined with trigger finger release can be performed safely in the same operative setting 1, 2

Important Clinical Caveats

Diabetes Consideration

• While the patient denies diabetes, this should be confirmed as diabetic patients have trigger finger affecting up to 20% of adults with diabetes and are less responsive to conservative measures 3
• Diabetic patients may benefit from early surgical release given lower efficacy of steroid injections 3

Post-Operative Monitoring

• Patients should be monitored for potential complications including incomplete release, nerve injury, or development of additional trigger fingers 2
• The mean interval for development of trigger finger after carpal tunnel release is approximately 5-6 months when it occurs post-operatively 6, 7

Documentation Requirements

The clinical documentation supports medical necessity by demonstrating:

• Clear diagnosis with clinical findings (inability to flex, triggering, pain) 2
• Failed conservative management over appropriate timeframe 3, 4
• Functional impairment affecting work and daily activities 2, 3
• Concurrent carpal tunnel syndrome with appropriate symptoms 1, 4

The request for 2 units of CPT 26440 is appropriate if addressing trigger finger in the left middle finger plus another digit, or if billing separately for concurrent procedures. Clarification of the exact surgical plan (trigger finger release alone vs. combined with carpal tunnel release) would optimize coding accuracy.