Chapter DWD 81

DWD 81.04(5)(d)3. 3. The patient’s functional status, especially vocational activity, is objectively improving, as evidenced by documentation in the medical record or successive reports of work ability of less restrictive limitations on activity.

DWD 81.04(5)(e) (e) There is an incapacitating exacerbation of the patient’s condition. Additional treatment for the incapacitating exacerbation shall comply with and may not exceed the guidelines in this chapter.

DWD 81.04 History History: CR 07-019: cr. Register October 2007 No. 622, eff. 11-1-07.

DWD 81.05 DWD 81.05 Guidelines for medical imaging.

DWD 81.05(1) (1) General principles.

DWD 81.05(1)(a) (a) Documentation. Except for emergency evaluation of significant trauma, a health care provider shall document in the medical record an appropriate history and physical examination, along with a review of any existing medical records and laboratory or imaging studies regarding the patient’s condition before ordering any imaging study. All medical imaging shall comply with all of the following:

DWD 81.05(1)(b) (b) Effective imaging. A health care provider shall initially order the single most effective imaging study for diagnosing the suspected etiology of a patient’s condition. No concurrent or additional imaging studies shall be ordered until the results of the first study are known and reviewed by the treating health care provider. If the first imaging study is negative, no additional imaging is necessary except for repeat and alternative imaging allowed under pars. (e) and (f).

DWD 81.05(1)(c) (c) Appropriate imaging. Imaging solely to rule out a diagnosis not seriously being considered as the etiology of the patient’s condition is not necessary.

DWD 81.05(1)(d) (d) Routine imaging. Imaging on a routine basis is not necessary unless the information from the study is necessary to develop a treatment plan.

DWD 81.05(1)(e) (e) Repeat imaging. Repeat imaging of the same views of the same body part with the same imaging modality is not necessary except for any of the following:

DWD 81.05(1)(e)1. 1. To diagnose a suspected fracture or suspected dislocation.

DWD 81.05(1)(e)2. 2. To monitor a therapy or treatment that is known to result in a change in imaging findings and imaging of these changes are necessary to determine the efficacy of the therapy or treatment; repeat imaging is not appropriate solely to determine the efficacy of physical therapy or chiropractic treatment.

DWD 81.05(1)(e)3. 3. To follow up a surgical procedure.

DWD 81.05(1)(e)4. 4. To diagnose a change in the patient’s condition marked by new or altered physical findings.

DWD 81.05(1)(e)5. 5. To evaluate a new episode of injury or exacerbation that in itself warrants an imaging study.

DWD 81.05(1)(e)6. 6. When the treating health care provider and a radiologist from a different practice have reviewed a previous imaging study and agree that it is a technically inadequate study.

DWD 81.05(1)(f) (f) Alternative imaging.

DWD 81.05(1)(f)1. 1. Persistence of a patient’s subjective complaint or failure of the condition to respond to treatment are not legitimate indications for repeat imaging. In this instance an alternative imaging study may be necessary if another etiology of the patient’s condition is suspected because of the failure of the condition to improve.

DWD 81.05(1)(f)2. 2. Alternative imaging may not follow up negative findings unless there has been a change in the suspected etiology and the first imaging study is not an appropriate evaluation for the suspected etiology.

DWD 81.05(1)(f)3. 3. Alternative imaging may follow up abnormal but inconclusive findings in another imaging study. An inconclusive finding may not provide an adequate basis for accurate diagnosis.

DWD 81.05(2) (2) Specific imaging procedures for low back pain.

DWD 81.05(2)(a) (a) Except for the emergency evaluation of significant trauma, a health care provider shall document in the medical record an appropriate history and physical examination, along with a review of any existing medical records and laboratory or imaging studies regarding the patient’s condition, before ordering any imaging study of the low back.

DWD 81.05(2)(b) (b) A health care provider may order computed tomography scanning for any of the following:

DWD 81.05(2)(b)1. 1. When cauda equina syndrome is suspected.

DWD 81.05(2)(b)2. 2. For evaluation of progressive neurologic deficit.

DWD 81.05(2)(b)3. 3. When bony lesion is suspected on the basis of other tests or imaging procedures.

DWD 81.05(2)(c) (c) Except as specified in par. (b), a health care provider may not order computed tomography scanning in the first 4 weeks after an injury. Computed tomography scanning is necessary after 4 weeks if the patient continues with symptoms and physical findings after the course of initial nonsurgical care and if the patient’s condition prevents the resumption of the regular activities of daily life, including regular vocational activities.

DWD 81.05(2)(d) (d) A health care provider may order magnetic resonance imaging scanning for any of the following:

DWD 81.05(2)(d)1. 1. When cauda equina syndrome is suspected.

DWD 81.05(2)(d)2. 2. For evaluation of progressive neurologic deficit.

DWD 81.05(2)(d)3. 3. When previous spinal surgery has been performed and there is a need to differentiate scar due to previous surgery from disc herniation, tumor, or hemorrhage.

DWD 81.05(2)(d)4. 4. Suspected discitis.

DWD 81.05(2)(e) (e) Except as specified in par. (d), a health care provider may not order magnetic resonance imaging scanning in the first 4 weeks after an injury. Magnetic resonance imaging scanning is necessary after 4 weeks if the patient continues with symptoms and physical findings after the course of initial nonsurgical care and if the patient’s condition prevents the resumption of the regular activities of daily life, including regular vocational activities.

DWD 81.05(2)(f) (f) A health care provider may order myelography for any of the following:

DWD 81.05(2)(f)1. 1. Myelography may be substituted for otherwise necessary computed tomography scanning or magnetic resonance imaging scanning in accordance with pars. (b) and (d), if those imaging modalities are not locally available.

DWD 81.05(2)(f)2. 2. In addition to computed tomography scanning or magnetic resonance imaging scanning, if there are progressive neurologic deficits or changes and computed tomography scanning or magnetic resonance imaging scanning has been negative.

DWD 81.05(2)(f)3. 3. For preoperative evaluation in cases of surgical intervention, but only if computed tomography scanning or magnetic resonance imaging scanning have failed to provide a definite preoperative diagnosis.

DWD 81.05(2)(g) (g) A health care provider may order computed tomography myelography for any of the following:

DWD 81.05(2)(g)1. 1. The patient’s condition is predominantly sciatica, there has been previous spinal surgery, and tumor is suspected.

DWD 81.05(2)(g)2. 2. The patient’s condition is predominantly sciatica, there has been previous spinal surgery, and magnetic resonance imaging scanning is equivocal.

DWD 81.05(2)(g)3. 3. When spinal stenosis is suspected and the computed tomography scanning or magnetic resonance imaging scanning is equivocal.

DWD 81.05(2)(g)4. 4. If there are progressive neurologic symptoms or changes and computed tomography scanning or magnetic resonance imaging scanning has been negative.

DWD 81.05(2)(g)5. 5. For preoperative evaluation in cases of surgical intervention, but only if computed tomography scanning or magnetic resonance imaging scanning have failed to provide a definite preoperative diagnosis.

DWD 81.05(2)(h) (h) A health care provider may order intravenous enhanced computed tomography scanning only if there has been previous spinal surgery, and the imaging study is being used to differentiate scar due to previous surgery from disc herniation or tumor, but only if intrathecal contrast for computed tomography-myelography is contraindicated and magnetic resonance imaging scanning is not available or is also contraindicated.

DWD 81.05(2)(i) (i) A health care provider may order enhanced magnetic resonance imaging scanning for any of the following:

DWD 81.05(2)(i)1. 1. There has been previous spinal surgery, and the imaging study is being used to differentiate scar due to previous surgery from disc herniation or tumor.

DWD 81.05(2)(i)2. 2. Hemorrhage is suspected.

DWD 81.05(2)(i)3. 3. Tumor or vascular malformation is suspected.

DWD 81.05(2)(i)4. 4. Infection or inflammatory disease is suspected.

DWD 81.05(2)(i)5. 5. Unenhanced magnetic resonance imaging scanning was equivocal.

DWD 81.05(2)(j) (j) A health care provider may order discography for any of the following:

DWD 81.05(2)(j)1. 1. All of the following are present:

DWD 81.05(2)(j)1.a. a. Back pain is the predominant complaint.

DWD 81.05(2)(j)1.b. b. The patient has failed to improve with initial nonsurgical management.

DWD 81.05(2)(j)1.c. c. Other imaging has not established a diagnosis.

DWD 81.05(2)(j)1.d. d. Lumbar fusion surgery or other surgical procedures are being considered as a therapy.

DWD 81.05(2)(j)2. 2. There has been previous spinal surgery, and pseudoarthrosis, recurrent disc herniation, annular tear, or internal disc disruption is suspected.

DWD 81.05(2)(k) (k) A health care provider may order computed tomography discography when it is necessary to view the morphology of a disc.

DWD 81.05(2)(L) (L) A health care provider may not order nuclear isotope imaging including technicium, indium, and gallium scans, unless tumor, stress fracture, infection, avascular necrosis, or inflammatory lesion is suspected on the basis of history, physical examination findings, laboratory studies, or the results of other imaging studies.

DWD 81.05(2)(m) (m) A health care provider may not order thermography for the diagnosis of any of the clinical categories of low back conditions in s. DWD 81.06 (1) (b).

DWD 81.05(2)(n) (n) A health care provider may order anterior-posterior and lateral X-rays of the lumbosacral spine for any of the following:

DWD 81.05(2)(n)1. 1. When there is a history of significant acute trauma as the precipitating event of the patient’s condition, and fracture, dislocation, or fracture dislocation is suspected.

DWD 81.05(2)(n)2. 2. When the history, signs, symptoms, or laboratory studies indicate possible tumor, infection, or inflammatory lesion.

DWD 81.05(2)(n)3. 3. For postoperative follow-up of lumbar fusion surgery.

DWD 81.05(2)(n)4. 4. When the patient is more than 50 years of age.

DWD 81.05(2)(n)5. 5. Before beginning a course of treatment with spinal adjustment or manipulation.

DWD 81.05(2)(n)6. 6. Eight weeks after an injury if the patient continues with symptoms and physical findings after the course of initial nonsurgical care and if the patient’s condition prevents the resumption of the regular activities of daily life, including regular vocational activities.

DWD 81.05(2)(o) (o) A health care provider may not order anterior-posterior and lateral X-rays of the lumbosacral spine for any of the following:

DWD 81.05(2)(o)1. 1. To verify progress during initial nonsurgical treatment.

DWD 81.05(2)(o)2. 2. To evaluate a successful initial nonsurgical treatment program.

DWD 81.05(2)(p) (p) A health care provider may order oblique X-rays of the lumbosacral spine for any of the following:

DWD 81.05(2)(p)1. 1. To follow up abnormalities detected on anterior-posterior or lateral X-ray.

DWD 81.05(2)(p)2. 2. For postoperative follow-up of lumbar fusion surgery.

DWD 81.05(2)(p)3. 3. To follow up spondylolysis or spondylolisthesis not adequately diagnosed by other necessary imaging procedures.

DWD 81.05(2)(q) (q) A health care provider may not order oblique X-rays of the lumbosacral spine as part of a package of X-rays including anterior-posterior and lateral X-rays of the lumbosacral spine.

DWD 81.05(2)(r) (r) A health care provider may not order electronic X-ray analysis of plain radiographs and diagnostic ultrasound of the lumbar spine for diagnosis of any of the low back conditions in s. DWD 81.06 (1) (b).

DWD 81.05 History History: CR 07-019: cr. Register October 2007 No. 622, eff. 11-1-07.

DWD 81.06 DWD 81.06 Low back pain.

DWD 81.06(1) (1) Diagnostic procedures for the evaluation of low back pain.

DWD 81.06(1)(a) (a) A health care provider shall determine the nature of the low back condition before initiating treatment.

DWD 81.06(1)(b) (b) A health care provider shall perform and document an appropriate history and physical examination. Based on the history and physical examination the health care provider shall assign the patient at each visit to the appropriate clinical category under subds. 1. to 4. The health care provider shall document the diagnosis in the medical record. For the purposes of subds. 2. and 3., “radicular pain” means pain radiating distal to the knee, or pain conforming to a dermatomal distribution, and accompanied by anatomically congruent motor weakness, or reflex changes. This section does not apply to fractures of the lumbar spine, or low back pain due to an infectious, immunologic, metabolic, endocrine, neurologic, visceral, or neoplastic disease process.

DWD 81.06(1)(b)1. 1. Regional low back pain, includes referred pain to the leg above the knee unless it conforms to an L2, L3, or L4 dermatomal distribution and is accompanied by anatomically congruent motor weakness or reflex changes. Regional low back pain includes the diagnoses of lumbar, lumbosacral, or sacroiliac strain, sprain, myofascial syndrome, musculoligamentous injury, soft tissue injury, spondylosis, and other diagnoses for pain believed to originate in the discs, ligaments, muscles, or other soft tissues of the lumbar spine or sacroiliac joints and that effects the lumbosacral region, with or without referral to the buttocks or leg, or both above the knee, including ICD-9-CM codes 720 to 720.9, 721, 721.3, 721.5 to 721.90, 722, 722.3, 722.32, 722.5, 722.51, 722.52, 722.6, 722.9, 722.90, 722.93, 724.2, 724.5, 724.6, 724.8, 724.9, 732.0, 737 to 737.9, 738.4, 738.5, 739.2 to 739.4, 756.1 to 756.19, 847.2 to 847.9, 922.3, 926.1, 926.11, and 926.12.

DWD 81.06(1)(b)2. 2. Radicular pain, with or without regional low back pain, with static or no neurologic deficit. This includes the diagnoses of sciatica; lumbar or lumbosacral radiculopathy, radiculitis, or neuritis; displacement or herniation of intervertebral disc with myelopathy, radiculopathy, radiculitis, or neuritis; spinal stenosis with myelopathy, radiculopathy, radiculitis, or neuritis; and any other diagnoses for pain in the leg below the knee believed to originate with irritation of a nerve root in the lumbar spine, including ICD-9-CM codes 721.4, 721.42 721.91, 722.1, 722.10, 722.2, 722.7, 722.73, 724.0, 724.00, 724.02, 724.09, 724.3, 724.4, and 724.9. In these cases, neurologic findings on history and physical examination are either absent or do not show progressive deterioration.

DWD 81.06(1)(b)3. 3. Radicular pain, with or without regional low back pain, with progressive neurologic deficit. This includes the same diagnoses as subd. 2., except this subdivision applies when there is a history of progressive deterioration in the neurologic symptoms and physical findings which include worsening sensory loss, increasing muscle weakness, or progressive reflex changes.

DWD 81.06(1)(b)4. 4. Cauda equina syndrome, which is a syndrome characterized by anesthesia in the buttocks, genitalia, or thigh and accompanied by disturbed bowel and bladder function, including ICD-9-CM codes 344.6, 344.60, and 344.61.

DWD 81.06(1)(c) (c) A health care provider may not order laboratory tests in the evaluation of a patient with regional low back pain, radicular pain, or cauda equina syndrome, except for any of the following:

DWD 81.06(1)(c)1. 1. When a patient’s history, age, or examination suggests infection, metabolic-endocrinologic disorders, tumorous conditions, systemic musculoskeletal disorders, such as rheumatoid arthritis or ankylosing spondylitis.

DWD 81.06(1)(c)2. 2. To evaluate potential adverse side effects of medications.

DWD 81.06(1)(c)3. 3. As part of a preoperative evaluation.