Utilization Review Checklist
Triangular Fibrocartilage Complex (TFCC) Tear
Derived from the ACOEM Hand, Wrist and Forearm Disorders Guideline, edition 14 July 2025, as adopted into the California MTUS 2 January 2026. CPT 29846, 25107. ICD-10 S63.59, M24.13.
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
Presumptive Diagnosis
All of the following
Ulnar-sided wrist pain made worse with activity
“● ulnar-sided wrist pain made worse with activity,” — p. 412
AND
Ulnar carpal joint tenderness that is not focally tender over an extensor compartment
“● ulnar carpal joint tenderness that is not focally tender over an extensor compartment, and” — p. 412
AND
Increasing pain with ulnar deviation with axial loading and/or grind
“● increasing pain with ulnar deviation with axial loading and/or grind.” — p. 412
Confirmatory Diagnosis
Required
MRI or MR arthrogram consistent with a TFCC tear
“A confirmatory diagnosis additionally requires an MRI or MR arthrogram consistent with a TFCC tear.” — p. 412
Conservative Care
Required
Failure of approximately 3-6 weeks of nonoperative treatment — at least 3 weeks
“Surgical repair considerations are failure of approximately 3-6 weeks of nonoperative treatment.” — p. 412
Surgical Considerations (arthroscopic or open repair)
Required
Repair requested for instability, concomitant fractures, or symptoms persisting without trending towards resolution
“Surgical repair (arthroscopic or open) is recommended for patients with instability, concomitant fractures, or symptoms that persist without trending towards resolution despite non-operative treatment and the passage of approximately 3 to 6 weeks.” — p. 412
Procedures — the guideline treats each separately
Arthroscopic or open surgical repair of a TFCC tear
Recommended.
Strength of Evidence — Recommended, Insufficient Evidence (I) · confidence moderate
The conservative threshold here is measured in WEEKS — approximately three to six — which is far shorter than most surgical indications in this chapter. Instability and concomitant fractures are named in the recommendation as indications in their own right, so a wrist that is unstable does not wait out the non-operative trial. Arthroscopic and open repair are both supported.