DWD 81.08(3)(f)
(f)
Mechanical traction. All of the following guidelines apply to mechanical traction:
DWD 81.08(3)(f)1.b.
b. Maximum treatment frequency is up to 3 times per week for the first one to 3 weeks decreasing in frequency until the end of the maximum treatment duration period in
subd. 1. c.
DWD 81.08(3)(f)1.c.
c. Maximum treatment duration is 12 weeks in a clinical setting but only if used in conjunction with other therapies.
DWD 81.08(3)(f)2.
2. Home use of a mechanical traction device may be prescribed as follow-up to use of traction in a clinical setting if it has proven to be effective treatment and is expected to continue to be effective treatment. Initial use of a mechanical traction device shall be in a supervised setting in order to ensure proper patient education. All of the following guidelines apply to home use of a mechanical traction device:
DWD 81.08(3)(f)2.b.
b. A patient may use the mechanical traction device for one month, at which time effectiveness of the treatment shall be reevaluated by a health care provider before continuing home use of the device.
DWD 81.08(3)(g)
(g)
Acupuncture treatments. For purposes of this paragraph, “acupuncture treatments" include endorphin-mediated analgesic therapy that includes classic acupuncture and acupressure. All of the following guidelines apply to acupuncture treatments:
DWD 81.08(3)(g)2.
2. Maximum treatment frequency is up to 3 times per week for one to 3 weeks and decreasing in frequency until the end of the maximum treatment duration period in
subd. 3.
DWD 81.08(3)(h)
(h)
Manual therapy. For purposes of this paragraph, “manual therapy" includes soft tissue and joint mobilization, therapeutic massage, and manual traction. All of the following guidelines apply to manual therapy:
DWD 81.08(3)(h)2.
2. Maximum treatment frequency is up to 5 times per week for the first one to 2 weeks decreasing in frequency until the end of the maximum treatment duration period in
subd. 3.
DWD 81.08(3)(i)
(i)
Phoresis. For purposes of this paragraph, “phoresis" includes iontophoresis and phonophoresis. All of the following guidelines apply to phoresis:
DWD 81.08(3)(i)2.
2. Maximum treatment frequency is up to 3 times per week for the first one to 3 weeks and decreasing in frequency until the end of the maximum treatment duration period in
subd. 3.
DWD 81.08(3)(j)
(j)
Bedrest. Prolonged restriction of activity and immobilization are detrimental to a patient's recovery. Bedrest may not be prescribed for more than 7 days.
DWD 81.08(3)(k)
(k)
Spinal braces and other movement restricting appliances. Spinal braces and other movement-restricting appliances required for longer than 2 weeks shall be accompanied by active muscle strengthening exercise to avoid deconditioning and prolonged disability. All of the following guidelines apply to spinal braces and other movement-restricting appliances:
DWD 81.08(3)(k)2.
2. Maximum treatment frequency is limited to intermittent use during times of increased physical stress or prophylactic use at work.
DWD 81.08(3)(k)3.
3. Maximum continuous duration is 3 weeks unless patient is status postfusion.
DWD 81.08(4)(a)(a) Active treatment modalities shall be used as set forth in
pars. (b) to
(f). A health care provider's use of active treatment modalities may extend past the 12-week limit on passive treatment modalities, so long as the maximum durations for the active treatment modalities are not exceeded.
DWD 81.08(4)(b)
(b) Education shall teach the patient about pertinent anatomy and physiology as it relates to spinal function for the purpose of injury prevention. Education includes training on posture, biomechanics, and relaxation. The maximum number of treatments is 3 visits, which include an initial education and training session and 2 follow-up visits.
DWD 81.08(4)(c)
(c) Posture and work method training shall instruct the patient in the proper performance of job activities. Topics include proper positioning of the trunk, back and arms, use of optimum biomechanics in performing job tasks, and appropriate pacing of activities. Methods may include didactic sessions, demonstrations, exercises, and simulated work tasks. The maximum number of treatments is 3 visits.
DWD 81.08(4)(d)
(d) Worksite analysis and modification shall examine the patient's work station, tools, and job duties. A health care provider may make recommendations for the alteration of the work station, selection of alternate tools, modification of job duties, and provision of adaptive equipment. The maximum number of treatments is 3 visits.
DWD 81.08(4)(e)
(e) Exercise, which is important to the success of an initial nonsurgical treatment program and a return to normal activity, shall include active patient participation in activities designed to increase flexibility, strength, endurance, or muscle relaxation. Exercise shall, at least in part, be specifically aimed at the musculature of the thoracic spine. Aerobic exercise and extremity strengthening may be performed as adjunctive treatment but may not be the primary focus of the exercise program.
DWD 81.08(4)(f)
(f) Exercises shall be evaluated to determine if the desired goals are being attained. Strength, flexibility, and endurance shall be objectively measured. A health care provider may objectively measure the treatment response as often as necessary for optimal care after the initial evaluation.
Subdivisions 1. and
2. govern supervised and unsupervised exercise, except for computerized exercise programs and health clubs, which are governed by
s. DWD 81.13.
DWD 81.08(4)(f)1.
1. `Guidelines for supervised exercise.' One goal of an exercise program shall be to teach the patient how to maintain and maximize any gains experienced from exercise. Self-management of the condition shall be promoted. All of the following guidelines apply to supervised exercise:
DWD 81.08(4)(f)1.a.
a. Maximum treatment frequency is 3 times per week for 3 weeks and may decrease with time until the end of the maximum treatment duration period in
subd. 1. b.
DWD 81.08(4)(f)2.
2. `Guidelines for unsupervised exercise.' Unsupervised exercise shall be provided in the least intensive setting appropriate to the goals of the exercise program and may supplement or follow the period of supervised exercise. All of the following guidelines apply to unsupervised exercise:
DWD 81.08(4)(f)2.a.
a. Maximum treatment frequency is one to 3 visits for instruction and monitoring.
DWD 81.08(5)(a)(a) Injection modalities are necessary as set forth in
pars. (b) to
(d). A health care provider's use of injections may extend past the 12-week limit on passive treatment modalities, so long as the maximum treatment for injections is not exceeded.
DWD 81.08(5)(b)
(b) For purposes of this subsection, “therapeutic injections" include trigger points injections, facet joint injections, facet nerve blocks, sympathetic nerve blocks, epidurals, nerve root blocks, and peripheral nerve blocks. Therapeutic injections may only be given in conjunction with active treatment modalities directed to the same anatomical site.
DWD 81.08(5)(b)1.
1. All of the following guidelines apply to trigger point injections:
DWD 81.08(5)(b)1.b.
b. Maximum treatment frequency is once per week if there is a positive response to the first injection at that site. If subsequent injections at that site demonstrate diminishing control of symptoms or fail to facilitate objective functional gains, then trigger point injections shall be redirected to other areas or discontinued. Only 3 injections per patient visit.
DWD 81.08(5)(b)2.
2. All of the following guidelines apply to facet joint injections and facet nerve blocks:
DWD 81.08(5)(b)2.b.
b. Maximum treatment frequency is once every 2 weeks if there is a positive response to the first injection or block. If subsequent injections or blocks demonstrate diminishing control of symptoms or fail to facilitate objective functional gains, then injections or blocks shall be discontinued. Only 3 injections or blocks per patient visit.
DWD 81.08(5)(b)3.b.
b. Maximum treatment frequency may permit repeat injection 2 weeks after the previous injection if there is a positive response to the first block. Only 3 injections per patient visit.
DWD 81.08(5)(b)4.b.
b. Maximum treatment frequency is once every 2 weeks if there is a positive response to the first injection. If subsequent injections demonstrate diminishing control of symptoms or fail to facilitate objective functional gains, then injections shall be discontinued. Only one injection per patient visit.
DWD 81.08(5)(c)
(c) For purposes of this paragraph, “lytic or sclerosing injections" include radio frequency denervation of the facet joints. These injections may only be given in conjunction with active treatment modalities directed to the same anatomical site. All of the following guidelines apply to lytic or sclerosing injections:
DWD 81.08(5)(d)
(d) Prolotherapy and botulinum toxin injections are not necessary in the treatment of thoracic back problems.
DWD 81.08(6)
(6) Surgery including decompression procedures. DWD 81.08(6)(b)
(b) In order to optimize the beneficial effect of surgery, postoperative therapy with active and passive treatment modalities may be provided, even if these modalities had been used in the preoperative treatment of the condition. In the postoperative period the maximum treatment duration with passive treatment modalities in a clinical setting from the initiation of the first passive modality used, except bedrest or bracing, is as follows:
DWD 81.08(6)(b)1.
1. Eight weeks following decompression or implantation of a spinal cord stimulator or intrathecal drug delivery system.
DWD 81.08(6)(d)
(d) The surgical therapies in
subds. 1. and
2. have very limited application and require a personality or psychosocial evaluation that indicates the patient is likely to benefit from the treatment.
DWD 81.08(6)(d)1.
1. Spinal cord stimulator may be necessary for a patient who has neuropathic pain and has had a favorable response to a trial screening period.
DWD 81.08(6)(d)2.
2. Intrathecal drug delivery system may be necessary for a patient who has somatic or neuropathic pain and has had a favorable response to a trial screening period.
DWD 81.08(7)
(7) Chronic management. Chronic management of thoracic back pain shall be provided according to the guidelines of
s. DWD 81.13.
DWD 81.08(8)(a)(a) A health care provider may direct the use of durable medical equipment only in certain specific situations as specified in
pars. (b) to
(e).
DWD 81.08(8)(c)
(c) For patients using electrical muscle stimulation or mechanical traction devices at home, the device and any required supplies are necessary within the guidelines of
sub. (3) (e) and
(f).
DWD 81.08(8)(d)
(d) Exercise equipment for home use, including bicycles, treadmills, and stairclimbers, are necessary only as part of an approved chronic management program. This equipment is not necessary during initial nonoperative care or during reevaluation and surgical therapy. If the employer has an appropriate exercise facility on its premises with the prescribed equipment, the insurer may mandate the use of that facility instead of authorizing purchase of equipment for home use.
DWD 81.08(8)(d)1.
1. `Indications.' The patient is deconditioned and requires reconditioning that may be accomplished only with the use of the prescribed exercise equipment. A health care provider shall document specific reasons why the exercise equipment is necessary and may not be replaced with other activities.
DWD 81.08(8)(d)2.
2. `Requirements.' The use of the equipment shall have specific goals and there shall be a specific set of prescribed activities.
DWD 81.08(8)(e)
(e) All of the following durable medical equipment is not necessary for home use for thoracic back pain conditions:
DWD 81.08(8)(e)1.
1. Whirlpools, Jacuzzis, hot tubs, or special bath or shower attachments.
DWD 81.08(9)
(9) Evaluation of treatment by health care provider. DWD 81.08(9)(a)(a) A health care provider shall evaluate at each visit whether the treatment is medically necessary and shall evaluate whether initial nonsurgical management is effective according to
pars. (b) to
(e). No later than the time for treatment response established for the specific modality in
subs. (3) to
(5), a health care provider shall evaluate whether the passive, active, injection, or medication treatment modality is resulting in progressive improvement in
pars. (b) to
(e).
DWD 81.08(9)(b)
(b) The patient's subjective complaints of pain or disability are progressively improving, as evidenced by documentation in the medical record of decreased distribution, frequency, or intensity of symptoms.
DWD 81.08(9)(c)
(c) The objective clinical findings are progressively improving, as evidenced by documentation in the medical record of resolution or objectively measured improvement in physical signs of injury.
DWD 81.08(9)(d)
(d) The patient's functional status, especially vocational activity, is progressively improving, as evidenced by documentation in the medical record or documentation of work ability involving less restrictive limitations on activity.
DWD 81.08(9)(e)
(e) If there is not progressive improvement in at least 2 categories specified in
pars. (b) to
(d), the modality shall be discontinued or significantly modified or a health care provider shall reconsider the diagnosis. The evaluation of the effectiveness of the treatment modality may be delegated to another health care provider.
