DWD 81.12(1)(c)3.
3. The patient exhibits one of the clinical findings of
subd. 3. a. in combination with the test results of
subd. 3. b.
DWD 81.12(1)(c)3.a.
a. Subjective sensory symptoms in a dermatomal distribution that may include radiating pain, burning, numbness, tingling or paresthesia, or objective clinical findings of nerve root specific motor deficit, reflex changes, or positive electromyography.
DWD 81.12(1)(c)3.b.
b. Medical imaging test results that correlate with the level of nerve root involvement consistent with both the subjective and objective findings.
DWD 81.12(1)(d)
(d)
Lumbar arthrodesis with or without instrumentation. A health care provider may perform surgery for a lumbar arthrodesis when any of the following diagnoses are present to indicate that the surgery is reasonably required:
DWD 81.12(1)(d)1.
1. Unstable lumbar vertebral fracture, ICD-9-CM codes 805.4, 805.5, 806.4, and 806.5.
DWD 81.12(1)(d)2.
2. For a second or third surgery only, documented reextrusion or redisplacement of lumbar intervertebral disc, ICD-9-CM code 722.10, after previous successful disc surgery at the same level and new lumbar radiculopathy with or without incapacitating back pain, ICD-9-CM code 724.4. Documentation under this subdivision shall include a magnetic resonance imaging scan or computed tomography scan or a myelogram.
DWD 81.12(1)(d)3.
3. Traumatic spinal deformity including a history of compression or wedge fracture or fractures, ICD-9-CM code 733.1, and demonstrated acquired kyphosis or scoliosis, ICD-9-CM codes 737.1, 737.10, 737.30, 737.41, and 737.43.
DWD 81.12(1)(d)4.
4. Incapacitating low back pain, ICD-9-CM code 724.2, for longer than 3 months, and any of the following conditions involving lumbar segments L-3 and below is present:
DWD 81.12(1)(d)4.a.
a. For the first surgery only, degenerative disc disease, ICD-9-CM code 722.4, 722.5, 722.6, or 722.7, with postoperative documentation of instability created or found at the time of surgery, or positive discogram at one or 2 levels.
DWD 81.12(1)(d)5.
5. A health care provider may not perform a lumbar arthrodesis as the first primary surgical procedure for a new, acute lumbosacral disc herniation with unilateral radiating leg pain in a radicular pattern with or without neurological deficit.
DWD 81.12(2)(a)(a)
General. Initial nonsurgical, surgical, and chronic management guidelines for upper extremity disorders are set forth in
s. DWD 81.09 (1) to
(16).
DWD 81.12(2)(b)
(b) Rotator cuff repair. A health care provider may perform rotator cuff surgery for any of the following diagnoses:
DWD 81.12(2)(b)1.
1. Rotator cuff syndrome of the shoulder, ICD-9-CM code 726.1, and allied disorders, including unspecified disorders of shoulder bursae and tendons, ICD-9-CM code 726.10; calcifying tendinitis of shoulder, ICD-9-CM code 726.11; bicipital tenosynovitis, ICD-9-CM code 726.12; and other specified disorders, ICD-9-CM code 726.19.
DWD 81.12(2)(c)
(c)
Criteria and indications for rotator cuff repair. In addition to one of the diagnoses in
par. (b), both of the following conditions shall be satisfied to indicate that surgery for rotator cuff repair is necessary:
DWD 81.12(2)(c)1.
1. The patient's condition failed to improve in response to nonsurgical care with adequate initial nonsurgical treatment.
DWD 81.12(2)(c)2.b.
b. Weak or absent abduction and tenderness over rotator cuff or pain relief obtained with an injection of anesthetic for diagnostic or therapeutic trial.
DWD 81.12(2)(c)2.c.
c. Positive findings in arthrogram, magnetic resonance imaging scan, or ultrasound, or positive findings on previous arthroscopy, if performed.
DWD 81.12(2)(d)
(d)
Acromioplasty diagnosis. A health care provider may perform acromioplasty for the diagnosis of acromial impingement syndrome, ICD-9-CM codes 726.0 to 726.2. In addition to the diagnosis in this paragraph, both of the following conditions shall be satisfied to indicate that surgery is necessary:
DWD 81.12(2)(d)1.
1. The patient's condition has failed to improve in response to nonsurgical care after adequate initial nonsurgical care.
DWD 81.12(2)(d)2.
2. The patient's clinical findings exhibit pain with active elevation from 90 to 130 degrees, pain at night, and a positive impingement test.
DWD 81.12(2)(e)
(e)
Repair of acromioclavicular or costoclavicular ligaments. A health care provider may perform surgical repair of acromioclavicular or costoclavicular ligaments for the diagnosis of acromioclavicular separation, ICD-9-CM codes 831.04 to 831.14.
DWD 81.12(2)(e)1.
1. In addition to the diagnosis in this paragraph, the guidelines in
subds. 2. and
3. shall be satisfied for repair of acromioclavicular or costoclavicular ligaments.
DWD 81.12(2)(e)2.
2. The patient's condition or response to nonsurgical care includes any of the following:
DWD 81.12(2)(e)2.a.
a. Failure to improve after at least a one-week trial period in a support brace.
DWD 81.12(2)(e)3.
3. The patient's clinical findings exhibit localized pain at the acromioclavicular joint and prominent distal clavicle and radiographic evidence of separation at the acromioclavicular joint.
DWD 81.12(2)(f)
(f)
Excision of distal clavicle diagnosis. A health care provider may perform excision of the distal clavicle for any of the following diagnoses specified in
subd. 1. to
3.:
DWD 81.12(2)(f)2.
2. Osteoarthrosis of the acromioclavicular joint, ICD-9-CM codes 715.11, 715.21, and 715.31.
DWD 81.12(2)(g)
(g)
Criteria and indications for excision of distal clavicle. In addition to one of the diagnosis in
par. (f), all of the following conditions shall be satisfied for excision of distal clavicle:
DWD 81.12(2)(g)1.
1. The patient's condition failed to improve in response to nonsurgical care with adequate initial nonsurgical care.
DWD 81.12(2)(g)2.a.
a. Pain at the acromioclavicular joint, with aggravation of pain with motion of shoulder or carrying weight.
DWD 81.12(2)(g)2.b.
b. Confirmation that separation of the acromioclavicular joint is unresolved and prominent distal clavicle, or pain relief obtained with an injection of anesthetic for diagnostic or therapeutic trial.
DWD 81.12(2)(g)2.c.
c. Separation at the acromioclavicular joint with weight-bearing films or severe degenerative joint disease at the acromioclavicular joint noted on X-rays.
DWD 81.12(2)(h)
(h)
Repair of shoulder dislocation or subluxation, any procedure. DWD 81.12(2)(h)1.1. A health care provider may perform surgical repair of a shoulder dislocation for any of the following diagnoses:
DWD 81.12(2)(h)2.
2. In addition to one of the diagnoses in this paragraph, all of the following clinical findings shall exist for repair of a shoulder dislocation:
DWD 81.12(2)(h)2.a.
a. The patient exhibits a history of multiple dislocations or subluxations that inhibit activities of daily living.
DWD 81.12(2)(h)2.b.
b. X-ray findings are consistent with multiple dislocations or subluxations.
DWD 81.12(2)(i)1.1. A health care provider may perform surgical repair of a proximal biceps tendon for the diagnosis of proximal rupture of the biceps, ICD-9-CM code 727.62 or 840.8.
DWD 81.12(2)(i)2.
2. In addition to the diagnosis in
subd. 1., both of the following conditions shall be satisfied for repair of proximal biceps tendon:
DWD 81.12(2)(i)2.a.
a. The procedure may be done alone or in conjunction with another necessary repair of the rotator cuff.
DWD 81.12(2)(i)2.b.
b. The patient's clinical findings exhibit pain that does not resolve with attempt to use arm and palpation of “bulge" in upper aspect of arm.
DWD 81.12(2)(m)
(m)
Muscle pain syndromes. Surgery is not necessary for muscle pain syndromes.
DWD 81.12(2)(n)
(n)
Traumatic sprains and strains. Surgery is not necessary for the treatment of traumatic sprains and strains, unless there is clinical evidence of complete tissue disruption. Patients with complete tissue disruption may need immediate surgery.
DWD 81.12(3)(a)1.1. A health care provider may perform surgical repair of the anterior cruciate ligament, including arthroscopic repair, for any of the following diagnoses:
DWD 81.12(3)(a)2.
2. In addition to one of the diagnoses in this paragraph, all of the conditions in
subd. 2. a. to
c. shall be satisfied for anterior cruciate ligament reconstruction. Pain alone is not an indication.
DWD 81.12(3)(a)2.a.
a. The patient gives a history of instability of the knee described as “buckling or giving way" with significant effusion at time of injury, or description of injury indicates a rotary twisting or hyperextension occurred.
DWD 81.12(3)(a)2.b.
b. There are objective clinical findings of positive Lachman's sign, positive pivot shift, or positive anterior drawer.
DWD 81.12(3)(a)2.c.
c. There are positive diagnostic findings with arthrogram, magnetic resonance imaging scan, or arthroscopy, and there is no evidence of severe compartmental arthritis.
DWD 81.12(3)(b)1.1. A health care provider may perform patellar tendon realignment for the diagnosis of dislocation of patellar, open, ICD-9-CM code 836.3; or closed, ICD-9-CM code 836.4; or chronic residuals of dislocation.
DWD 81.12(3)(b)2.
2. In addition to the diagnosis in this paragraph, all of the following conditions shall be satisfied for a patellar tendon realignment:
DWD 81.12(3)(b)2.a.
a. The patient gives a history of rest pain as well as pain with patellofemoral movement, and recurrent effusion, or recurrent dislocation.
DWD 81.12(3)(b)2.b.
b. There are objective clinical findings of patellar apprehension, synovitis, lateral tracking, or Q angle greater than 15 degrees.
DWD 81.12(3)(c)1.1. A health care provider may perform a knee joint replacement for degeneration of articular cartilage or meniscus of knee, ICD-9-CM codes 717.1 to 717.4.
DWD 81.12(3)(c)2.
2. In addition to the diagnosis in this paragraph, all of the following conditions shall be satisfied for a knee joint replacement:
DWD 81.12(3)(c)2.a.
a. The patient exhibits limited range of motion, night pain in the joint, or pain with weight-bearing, and no significant relief of pain with an adequate course of initial nonsurgical care.
DWD 81.12(3)(c)2.b.
b. The patient's diagnostic findings confirm there is significant loss or erosion of cartilage to the bone, and positive findings of advanced arthritis, and joint destruction with standing films, magnetic resonance imaging scan, or arthroscopy.
DWD 81.12(3)(d)1.1. A health care provider may perform an ankle, tarsal, or metatarsal fusion for either of the following diagnoses:
DWD 81.12(3)(d)1.a.
a. Malunion or nonunion of fracture of ankle, tarsal, or metatarsal, ICD-9-CM code 733.81 or 733.82.
DWD 81.12(3)(d)2.
2. In addition to one of the diagnoses in this paragraph, the following conditions shall be satisfied for an ankle, tarsal, or metatarsal fusion. For initial nonsurgical care the patient shall have failed to improve with an adequate course of initial nonsurgical care that included any of the following:
DWD 81.12(3)(d)2.a.
a. Immobilization, which may include casting, bracing, shoe modification, or other orthotics.
