Utilization Review Checklist
De Quervain Syndrome (First Dorsal Compartment Tenosynovitis)
Derived from the ACOEM Hand, Wrist and Forearm Disorders Guideline, edition 14 July 2025, as adopted into the California MTUS 2 January 2026. CPT 25000. ICD-10 M65.4.
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
All of the following
Positive Finkelstein's maneuver
“requires a positive Finkelstein's maneuver plus at least three of the following:” — p. 184
AND
At least three of: focal pain, worsening pain with thumb and/or wrist movement, tenderness, snapping or catching, swelling
“plus at least three of the following: ● pain that is focal over the first extensor tendon compartment, ● worsening pain in the first extensor compartment with movement of the thumb and/or wrist, ● tenderness over the first extensor compartment, (4) snapping or catching sensation when moving the thumb, and ● swelling over the first extensor tendon compartment.” — p. 184
At least 3 of the following:
Pain that is focal over the first extensor tendon compartment
“● pain that is focal over the first extensor tendon compartment,” — p. 184
OR
Worsening pain in the first extensor compartment with movement of the thumb and/or wrist
“● worsening pain in the first extensor compartment with movement of the thumb and/or wrist,” — p. 184
OR
Tenderness over the first extensor compartment
“● tenderness over the first extensor compartment,” — p. 184
OR
Snapping or catching sensation when moving the thumb
“(4) snapping or catching sensation when moving the thumb, and” — p. 184
OR
Swelling over the first extensor tendon compartment
“● swelling over the first extensor tendon compartment.” — p. 184
Conservative Care
All of the following
Failure of at least two nonoperative treatments
“● failure of at least two nonoperative treatments (i.e., activity modification, thumb spica splinting, anti-inflammatory medications, at least two to three iontophoresis treatments using glucocorticosteroids) and” — p. 184
At least 2 of the following:
Activity modification
“● failure of at least two nonoperative treatments (i.e., activity modification, thumb spica splinting, anti-inflammatory medications, at least two to three iontophoresis treatments using glucocorticosteroids) and” — p. 184
OR
Thumb spica splinting
“● failure of at least two nonoperative treatments (i.e., activity modification, thumb spica splinting, anti-inflammatory medications, at least two to three iontophoresis treatments using glucocorticosteroids) and” — p. 184
OR
Anti-inflammatory medications
“● failure of at least two nonoperative treatments (i.e., activity modification, thumb spica splinting, anti-inflammatory medications, at least two to three iontophoresis treatments using glucocorticosteroids) and” — p. 184
OR
At least two to three iontophoresis treatments using glucocorticosteroids
“● failure of at least two nonoperative treatments (i.e., activity modification, thumb spica splinting, anti-inflammatory medications, at least two to three iontophoresis treatments using glucocorticosteroids) and” — p. 184
AND
One glucocorticosteroid injection with documented short-term improvement, unless contraindicated
“● one glucocorticosteroid injection for which there is documented short-term improvement in symptoms (unless there is a documented contraindication for an injection)” — p. 184
Surgical Considerations (surgical release)
Required
Surgical release requested for subacute or chronic extensor compartment tenosynovitis failing to respond to injection
“Surgical release is recommended for patients with subacute or chronic extensor compartment tenosynovitis who fail to respond to injection.” — p. 184
Procedures — the guideline treats each separately
Surgical release for subacute or chronic extensor compartment tenosynovitis
Recommended.
Strength of Evidence — Recommended, Insufficient Evidence (I) · confidence moderate
The guideline is explicit that release is for patients 'who fail to respond to injection', so the injection is not optional — it is the gate. Document one injection with short-term improvement, or a contraindication to injecting, and two other failed treatments alongside it.