Is a 30-year-old male patient with worsening elbow pain, numbness, and tingling, despite normal electrodiagnostic testing (Electromyography (EMG) and Nerve Conduction Study (NCS)) results, a candidate for surgical procedures 64718 (revision of ulnar nerve at elbow) and 26055 (incision of finger tendon sheath) to address his symptoms of cubital tunnel syndrome and trigger finger?

Medical Necessity Determination: Ulnar Nerve Transposition and Trigger Finger Release

Direct Answer

The requested ulnar nerve transposition (CPT 64718) is NOT medically necessary because electrodiagnostic testing (EMG/NCS) failed to confirm cubital tunnel syndrome, which is an absolute requirement per MCG criteria. The trigger finger release (CPT 26055) for the right middle finger IS medically necessary given documented clicking, failed conservative management, and prior incomplete release. 1

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Analysis of Ulnar Nerve Transposition (CPT 64718)

Critical Missing Criterion

MCG explicitly requires that electrodiagnostic testing confirms cubital tunnel syndrome as one of the mandatory criteria for surgical intervention. 1 Your case documentation states:

• EMG and NCS results: NORMAL
• This directly contradicts the MCG requirement: "Electrodiagnostic testing confirms cubital tunnel syndrome" - NOT MET

Why Normal Electrodiagnostic Testing Precludes Surgery

• Electrodiagnostic confirmation is essential because clinical symptoms alone (numbness, tingling, positive elbow flexion test) have poor specificity and can result from cervical radiculopathy, thoracic outlet syndrome, or other conditions 2, 3
• The American College of Radiology emphasizes that EMG and nerve conduction studies are necessary when neurologic symptoms suggest cubital tunnel syndrome to differentiate from other etiologies 3
• Normal electrodiagnostic studies indicate the ulnar nerve is conducting normally without evidence of compression, demyelination, or axonal loss 4, 5

Additional Diagnostic Considerations Before Surgery

Advanced imaging should be obtained before proceeding to surgery when electrodiagnostic testing is negative:

• T2-weighted MR neurography is the reference standard for imaging ulnar nerve entrapment, showing high signal intensity and nerve enlargement in true cubital tunnel syndrome 2, 6
• Dynamic ultrasound has 96% sensitivity and 81% specificity for detecting ulnar nerve dislocation and can identify structural causes of symptoms that EMG/NCS may miss 6
• Pain may be referred from cervical spine pathology, requiring broader diagnostic consideration when initial testing is negative 2, 3

Clinical Algorithm for This Patient

Given normal electrodiagnostic testing, the following steps should precede any surgical consideration:

1. Obtain MR neurography to evaluate for structural nerve pathology not detected by EMG/NCS 2, 6
2. Consider cervical spine imaging to rule out C8 radiculopathy as the source of ulnar-distribution symptoms 1
3. Repeat electrodiagnostic testing in 3-6 months if symptoms progress, as early cubital tunnel syndrome may initially show normal studies 4, 1
4. Continue conservative management including night splinting in extension and activity modification, as this is effective in early-stage disease 1, 7

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Analysis of Trigger Finger Release (CPT 26055)

Medical Necessity Established

The right middle finger trigger release IS medically necessary based on the following:

• Documented persistent clicking proximal to previous incision site indicates incomplete prior release or recurrent stenosis 3
• Failed conservative management including occupational therapy with stretching, strengthening, ROM exercises, and modalities - meeting MCG requirement 1
• Persistent mechanical dysfunction (clicking/crepitus) for years indicates structural pathology requiring surgical intervention 3

Justification for Revision Surgery

• The physical exam finding of "clicking proximal to the area of the previous incision" suggests the A1 pulley was incompletely released or scar tissue has formed causing recurrent triggering 8
• MCG criteria for musculoskeletal surgery includes "procedure required for musculoskeletal acquired dysfunction (eg, tendon repair)" - which revision trigger release addresses 1
• Conservative management has been exhausted with persistent symptoms, meeting the standard threshold for surgical intervention 1, 7

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Common Pitfalls to Avoid

Do not proceed with ulnar nerve surgery based solely on clinical symptoms when electrodiagnostic testing is normal - this violates evidence-based criteria and exposes the patient to unnecessary surgical risk including nerve injury, scarring, and potential worsening of symptoms 8, 1

Do not assume intermittent diminished sensation equals cubital tunnel syndrome - this finding has poor specificity and requires objective confirmation via EMG/NCS or advanced imaging 2, 3, 4

Do not confuse "provocative symptoms with elbow flexion test" with diagnostic confirmation - the elbow flexion test has limited diagnostic accuracy without electrodiagnostic correlation 4, 1

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Final Recommendation

Approve CPT 26055 (trigger finger release) as medically necessary.

Deny CPT 64718 (ulnar nerve transposition) as NOT medically necessary due to failure to meet MCG mandatory criterion of electrodiagnostic confirmation. Request MR neurography and/or repeat electrodiagnostic testing in 3-6 months if symptoms progress before reconsidering surgical authorization. 2, 6, 1