Wisconsin Legislature: DWD 81.12(3)(a)2.b.

2. The patient’s clinical findings exhibit any of the following:

a. Pain at the acromioclavicular joint, with aggravation of pain with motion of shoulder or carrying weight.

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.

c. Separation at the acromioclavicular joint with weight-bearing films or severe degenerative joint disease at the acromioclavicular joint noted on X-rays.

(h) Repair of shoulder dislocation or subluxation, any procedure.

1. A health care provider may perform surgical repair of a shoulder dislocation for any of the following diagnoses:

a. Recurrent dislocations, ICD-9-CM code 718.31.

b. Recurrent subluxations.

c. Persistent instability following traumatic dislocation.

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:

a. The patient exhibits a history of multiple dislocations or subluxations that inhibit activities of daily living.

b. X-ray findings are consistent with multiple dislocations or subluxations.

(i) Repair of proximal biceps tendon.

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.

2. In addition to the diagnosis in subd. 1., both of the following conditions shall be satisfied for repair of proximal biceps tendon:

a. The procedure may be done alone or in conjunction with another necessary repair of the rotator cuff.

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.

(j) Epicondylitis. Specific guidelines for surgery for epicondylitis are included in s. DWD 81.09 (11).

(k) Tendinitis. Specific guidelines for surgery for tendinitis are included in s. DWD 81.09 (12).

(L) Nerve entrapment syndromes. Specific guidelines for nerve entrapment syndromes are included in s. DWD 81.09 (13).

(m) Muscle pain syndromes. Surgery is not necessary for muscle pain syndromes.

(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.

(3) Lower extremity surgery.

(a) Anterior cruciate ligament reconstruction.

1. A health care provider may perform surgical repair of the anterior cruciate ligament, including arthroscopic repair, for any of the following diagnoses:

a. Old disruption of anterior cruciate ligament, ICD-9-CM code 717.83.

b. Sprain of cruciate ligament of knee, ICD-9-CM code 844.2.

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.

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.

b. There are objective clinical findings of positive Lachman’s sign, positive pivot shift, or positive anterior drawer.

c. There are positive diagnostic findings with arthrogram, magnetic resonance imaging scan, or arthroscopy, and there is no evidence of severe compartmental arthritis.

(b) Patellar tendon realignment.

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.

2. In addition to the diagnosis in this paragraph, all of the following conditions shall be satisfied for a patellar tendon realignment:

a. The patient gives a history of rest pain as well as pain with patellofemoral movement, and recurrent effusion, or recurrent dislocation.

b. There are objective clinical findings of patellar apprehension, synovitis, lateral tracking, or Q angle greater than 15 degrees.

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.

2. In addition to the diagnosis in this paragraph, all of the following conditions shall be satisfied for a knee joint replacement:

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.

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.

(d) Fusion; ankle, tarsal, metatarsal.

1. A health care provider may perform an ankle, tarsal, or metatarsal fusion for either of the following diagnoses:

a. Malunion or nonunion of fracture of ankle, tarsal, or metatarsal, ICD-9-CM code 733.81 or 733.82.

b. Traumatic arthritis, arthropathy, ICD-9-CM code 716.17.

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:

a. Immobilization, which may include casting, bracing, shoe modification, or other orthotics.

b. Anti-inflammatory medications.

3. The patient’s clinical findings exhibit both of the following and subd. 4.:

a. The patient gives a history of pain which is aggravated by activity and weight-bearing, and relieved by xylocaine injection.

b. There are objective findings on physical examination of malalignment or specific joint line tenderness, and decreased range of motion.

4. The patient’s diagnostic findings include medical imaging studies confirming the presence of any of the following:

a. Loss of articular cartilage and joint space narrowing.

b. Bone deformity with hypertrophic spurring and sclerosis.

c. Nonunion or malunion of a fracture.

(e) Lateral ligament ankle reconstruction.

1. A health care provider may perform ankle reconstruction surgery involving the lateral ligaments for any of the following diagnoses:

a. Chronic ankle instability, ICD-9-CM code 718.87.

b. Grade III sprain, ICD-9-CM codes 845.0 to 845.09.

2. In addition to one of the diagnoses in subd. 1., all of the clinical findings in subd. 3. shall be satisfied for a lateral ligament ankle reconstruction. For initial nonsurgical care, the patient shall have received an adequate course of initial nonsurgical care, including one of the following:

a. Immobilization with support, cast, or ankle brace.

b. A physical rehabilitation program that follows immobilization with support, cast, or ankle brace.

3. The patient’s clinical findings shall include all of the following:

a. The patient gives a history of ankle instability and swelling.

b. There is a positive anterior drawer sign on examination.

c. There are positive stress X-rays identifying motion at ankle or subtalar joint with at least a 15 degree lateral opening at the ankle joint, or demonstrable subtalar movement, and negative to minimal arthritic joint changes on X-ray, or ligamentous injury is shown on magnetic resonance imaging scan.

4. Prosthetic ligaments are not necessary for the treatment of lateral ligament ankle reconstruction.

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

DWD 81.13 Chronic management.

(1) Scope. This section applies to chronic management of all types of physical injuries, even if the injury is not specifically governed by this chapter. If a patient continues with symptoms and physical findings after all appropriate initial nonsurgical and surgical treatment has been rendered, and if the patient’s condition prevents the resumption of the regular activities of daily life including regular vocational activities, then the patient may be a candidate for chronic management. The purpose of chronic management is twofold: the patient should be made independent of health care providers in the ongoing care of a chronic condition; and the patient shall be returned to the highest functional status reasonably possible.

(a) Personality or psychological evaluation may be necessary for patients who are candidates for chronic management. A treating health care provider may perform this evaluation or may refer the patient for consultation with another health care provider in order to obtain a psychological evaluation. These evaluations may be used to assess the patient for a number of psychological conditions that may interfere with recovery from the injury. Since more than one of these psychological conditions may be present in a given case, a health care provider performing the evaluation shall consider all of the following:

1. Is symptom magnification occurring?

2. Does the patient exhibit an emotional reaction to the injury, such as depression, fear, or anger, that is interfering with recovery?

3. Are there other personality factors or disorders that are interfering with recovery?

4. Is the patient chemically dependent?

5. Are there any interpersonal conflicts interfering with recovery?

6. Does the patient have a chronic pain syndrome or psychogenic pain?

7. In cases in which surgery is a possible treatment, are psychological factors likely to interfere with the potential benefit of the surgery?

(b) Any of the chronic management modalities of sub. (2) may be used singly or in combination as part of a program of chronic management.

(c) No further passive treatment modalities or therapeutic injections are necessary, except as otherwise provided in ss. DWD 81.06 (3) (b), 81.07 (3) (b), 81.08 (3) (b), and 81.09 (3) (b).

(d) No further diagnostic evaluation is necessary unless there is the development of symptoms or physical findings that would in themselves warrant diagnostic evaluation.

(e) A program of chronic management shall include appropriate means by which use of scheduled medications can be discontinued or severely limited.

(2) Chronic management modalities.

(a) Home-based exercise programs. Home-based exercise programs consist of aerobic conditioning, stretching, and flexibility exercises, and strengthening exercises done by the patient on a regular basis at home without the need for supervision or attendance by a health care provider. Maximum effectiveness may require the use of certain durable medical equipment that may be prescribed within any applicable treatment guidelines in ss. DWD 81.06 to 81.10.

1. ‘Indications.’ Exercise is necessary on a long-term basis to maintain function.

2. ‘Guidelines.’ The patient shall receive specific instruction and training in the exercise program. Repetitions, durations, and frequencies of exercises shall be specified.

3. ‘Treatment.’ Treatment period is one to 3 visits for instruction and monitoring.

(b) Health clubs.

1. ‘Indications.’ The patient is deconditioned and requires a structured environment to perform prescribed exercises. A health care provider shall document the reasons why reconditioning may not be accomplished with a home-based program of exercise.