Is the request for codes 28035, 64708, 64727, 64782, 64787, A4649, and Q4133 with a diagnosis of tarsal tunnel syndrome (G57.52) medically necessary?

Medical Necessity Determination for Tarsal Tunnel Surgery

The requested procedures (codes 28035,64708,64727,64782,64787) are medically necessary for this patient with documented tarsal tunnel syndrome who has failed conservative management with corticosteroid injections and demonstrates clinical findings consistent with nerve compression. However, the medical necessity of codes A4649 and Q4133 (Grafix) cannot be determined from the documentation provided, as these products are indicated for diabetic foot ulcers, not routine surgical wound care following nerve decompression.

Surgical Indications Met

Core Criteria for Tarsal Tunnel Decompression

• Clinical diagnosis confirmed: Patient demonstrates persistent pain in the distribution of the posterior tibial nerve (lateral heel pain from sural nerve involvement, medial ankle pain from tibial nerve compression) 1, 2
• Conservative treatment failure documented: Multiple corticosteroid injections provided only temporary relief, meeting the requirement for failed nonsurgical management 1, 3
• Positive clinical examination: Pain on palpation of the posterior tibial nerve and surgical scar, consistent with nerve entrapment 2, 3

Critical Missing Element

The documentation does NOT clearly state that MRI or ultrasound confirms compression of the posterior tibial nerve within the tarsal tunnel, which is specifically required by MCG criteria A-0393 1. While an EMG was performed (mentioned in office note), imaging confirmation of nerve compression is not explicitly documented. This represents a partial criteria gap.

Nerve Decompression Procedures (64708,64727,64782,64787)

These codes appear medically necessary as the operative report documents multiple nerve decompressions that are clinically indicated for documented nerve entrapment 1, 2:

• Tibial neurolysis (64708): Addresses documented tibial nerve entrapment
• Medial and lateral plantar neurolysis (64727,64782): Appropriate for comprehensive tarsal tunnel release when symptoms involve plantar nerve distribution 3
• Sural neuroma excision with nerve burial: Addresses the documented neuroma causing lateral heel pain 4

Prognostic Factors Supporting Surgery

The patient demonstrates several positive predictors for surgical success 1:

• Positive Tinel's sign documented (pain upon palpation of nerve)
• Clear etiology identified (post-surgical neuroma, nerve compression)
• Failed conservative management with identifiable compression source

Wound Care Products - NOT Medically Necessary

Code A4649 (Surgical Supply, Miscellaneous)

Cannot determine medical necessity without specific documentation of what surgical supply is being requested. Standard surgical wound care supplies are typically included in the global surgical package.

Code Q4133 (Grafix)

NOT medically necessary per CPB 0244. Grafix products are specifically indicated for:

• Partial and full-thickness neuropathic diabetic foot ulcers
• Greater than 6 weeks duration
• No capsule, tendon, or bone exposed

This patient does not have a diabetic foot ulcer. The surgical incisions from tarsal tunnel release and neuroma excision are acute surgical wounds, not chronic neuropathic ulcers. There is no documentation of diabetes mellitus in the case summary 1, 2.

Common Pitfalls to Avoid

Diagnostic Confirmation

• Ensure imaging documentation: The MCG criteria specifically require MRI or ultrasound confirmation of nerve compression, not just EMG findings 1
• EMG alone is insufficient: While nerve conduction studies help confirm neuropathy, imaging must demonstrate the anatomical compression 3

Differential Diagnosis Considerations

The documented examination appropriately excludes 1, 5:

• Plantar fasciitis (different pain distribution)
• Radiculopathy (EMG would show different pattern)
• Vascular compromise (appears met per documentation)

Product Misapplication

Critical error to avoid: Applying skin substitutes designed for chronic diabetic ulcers to acute surgical incisions represents inappropriate use and will not meet coverage criteria 1.

Final Determination

APPROVE: CPT codes 28035,64708,64727,64782,64787 for tarsal tunnel decompression and nerve procedures

DENY: CPT codes A4649 and Q4133 - insufficient documentation for A4649; Q4133 does not meet indication criteria (not a diabetic foot ulcer)

Recommendation: Request clarification on imaging confirmation of nerve compression to fully satisfy MCG A-0393 criteria, though clinical presentation strongly supports the diagnosis 1, 2.