Utilization Review Checklist
Tarsal Tunnel Syndrome
Derived from the ACOEM Ankle and Foot Disorders Guideline, edition 29 January 2026, as adopted into the California MTUS 1 August 2026. CPT 28035. ICD-10 G57.5.
Draft — not reviewed or approved by COA. Prepared by Rette from the ACOEM guideline named above. This is not a COA document and does not reproduce COA’s own checklists.
CriteriaCheck if documented
Confirmatory Diagnosis
Required
A space-occupying lesion causing posterior tibial nerve impingement at the tarsal tunnel
“Surgical release of posterior tibial nerve impingement at the tarsal tunnel is recommended upon failure of conservative treatment and in the presence of a space- occupying lesion.” — p. 326
Conservative Care
Required
Failure of conservative treatment, including splinting
“Indications Tarsal tunnel syndrome unresponsive to splinting.” — p. 317
Surgical Considerations (surgical release)
Required
Release requested, with the patient counselled regarding potential lack of benefit
“Patients should be counseled regarding potential lack of benefit before consideration of surgery. There is no recommendation for any specific technique as there is a lack of quality evidence.” — p. 326
Procedures — the guideline treats each separately
Surgical release of posterior tibial nerve impingement at the tarsal tunnel
Recommended.
Strength of Evidence — Recommended, Insufficient Evidence (I) · confidence moderate
The recommendation turns on ONE fact: a space-occupying lesion. The guideline says release for nonspecific causes is 'otherwise expected to have mixed results' and that patients should be counselled about potential lack of benefit beforehand. Identify the lesion on imaging and record the counselling — without a lesion this request is on the weak side of the same sentence.