Is percutaneous needle aponeurotomy (PNA) medically necessary for a 64-year-old patient with Dupuytren's contracture of the left hand, with a 5-year history of slowly worsening contracture, now limiting activities, and no prior treatments or specified physical exam findings, including degree of contracture and table top test results?

Medical Necessity Determination for CPT 26040 - Left Hand Palmar Needle Aponeurotomy

The requested procedure CANNOT be determined as medically necessary based on the documentation provided, as critical clinical criteria required by the coverage policy are not documented, specifically the degree of contracture (≥20 degrees) and the table top test result.

Coverage Policy Requirements Not Met

The CPB policy explicitly requires three specific criteria for percutaneous needle aponeurotomy to be considered medically necessary:

• Palpable cord present in MCP or PIP joint (not documented)
• Contracture ≥20 degrees (not documented)
• Positive table top test - inability to place affected finger(s) and palm flat against table simultaneously (not documented)

The clinical documentation states only that "contracture of the ring finger on the left hand has started to limit her activities" without quantifying the degree of contracture or documenting examination findings.

What Is Missing From Documentation

Required Physical Examination Findings:

• Degree of contracture measurement in degrees for the affected ring finger at both MCP and PIP joints
• Table top test result - specifically whether the patient can or cannot place the palm and affected finger flat on a table surface simultaneously
• Presence and location of palpable cord(s) in the palmar fascia

Treatment History Gap:

• No documentation of prior conservative management attempts or why they were not appropriate
• No mention of whether the patient has tried observation, splinting, or other interventions

Clinical Context and Evidence

While Dupuytren's contracture is a progressive fibrotic condition affecting the palmar fascia that can cause debilitating finger flexion contractures 1, 2, and percutaneous needle aponeurotomy (PNA) is an established minimally invasive treatment option 1, 2, the medical necessity determination requires objective documentation of disease severity.

PNA has been shown to provide high patient satisfaction with fewer adverse events compared to open fasciectomy, though with higher recurrence rates 2. The procedure is appropriate for symptomatic contractures, but payers require objective criteria to establish that threshold has been met.

Recommendation for Authorization

This case should be PENDED for additional clinical information rather than denied outright. Request the following from the treating physician:

1. Specific degree of contracture measured in degrees at MCP and/or PIP joint of left ring finger
2. Table top test result - documented as positive or negative
3. Description of palpable cord location and characteristics
4. Any prior conservative treatments attempted or rationale for proceeding directly to intervention

Common Pitfall to Avoid

The presence of functional limitation alone ("started to limit her activities") does not satisfy objective medical necessity criteria without measurable physical examination findings. The 5-year history and progressive nature support clinical appropriateness, but documentation must include the specific metrics required by coverage policy.

If supplemental documentation confirms contracture ≥20 degrees and positive table top test with palpable cord, the procedure would meet medical necessity criteria and should be approved.