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.
DWD 81.12(3)(d)3.
3. The patient's clinical findings exhibit both of the following and
subd. 4.:
DWD 81.12(3)(d)3.a.
a. The patient gives a history of pain which is aggravated by activity and weight-bearing, and relieved by xylocaine injection.
DWD 81.12(3)(d)3.b.
b. There are objective findings on physical examination of malalignment or specific joint line tenderness, and decreased range of motion.
DWD 81.12(3)(d)4.
4. The patient's diagnostic findings include medical imaging studies confirming the presence of any of the following:
DWD 81.12(3)(e)1.1. A health care provider may perform ankle reconstruction surgery involving the lateral ligaments for any of the following diagnoses:
DWD 81.12(3)(e)2.
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:
DWD 81.12(3)(e)2.b.
b. A physical rehabilitation program that follows immobilization with support, cast, or ankle brace.
DWD 81.12(3)(e)3.
3. The patient's clinical findings shall include all of the following:
DWD 81.12(3)(e)3.c.
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.
DWD 81.12(3)(e)4.
4. Prosthetic ligaments are not necessary for the treatment of lateral ligament ankle reconstruction.
DWD 81.12 History
History: CR 07-019: cr. Register October 2007 No. 622, eff. 11-1-07. DWD 81.13(1)
(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.
DWD 81.13(1)(a)
(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:
DWD 81.13(1)(a)2.
2. Does the patient exhibit an emotional reaction to the injury, such as depression, fear, or anger, that is interfering with recovery?
DWD 81.13(1)(a)3.
3. Are there other personality factors or disorders that are interfering with recovery?
DWD 81.13(1)(a)5.
5. Are there any interpersonal conflicts interfering with recovery?
DWD 81.13(1)(a)6.
6. Does the patient have a chronic pain syndrome or psychogenic pain?
DWD 81.13(1)(a)7.
7. In cases in which surgery is a possible treatment, are psychological factors likely to interfere with the potential benefit of the surgery?
DWD 81.13(1)(b)
(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.
DWD 81.13(1)(d)
(d) No further diagnostic evaluation is necessary unless there is the development of symptoms or physical findings that would in themselves warrant diagnostic evaluation.
DWD 81.13(1)(e)
(e) A program of chronic management shall include appropriate means by which use of scheduled medications can be discontinued or severely limited.
DWD 81.13(2)(a)(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.
DWD 81.13(2)(a)1.
1. `Indications.' Exercise is necessary on a long-term basis to maintain function.
DWD 81.13(2)(a)2.
2. `Guidelines.' The patient shall receive specific instruction and training in the exercise program. Repetitions, durations, and frequencies of exercises shall be specified.
DWD 81.13(2)(a)3.
3. `Treatment.' Treatment period is one to 3 visits for instruction and monitoring.
DWD 81.13(2)(b)1.1. `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.
DWD 81.13(2)(b)2.
2. `Guidelines.' The program shall have specific prescribed exercises stated in objective terms, for example “30 minutes riding stationary bicycle three times per week." There shall be a specific set of prescribed activities and a specific timetable of progression in those activities, designed so that the goals can be achieved in the prescribed time. There shall be a prescribed frequency of attendance and the patient shall maintain adequate documentation of attendance. There shall be a prescribed duration of attendance.
DWD 81.13(2)(b)3.
3. `Treatment.' Treatment period is 13 weeks. Additional periods of treatment at a health club are not necessary unless there is documentation of attendance and progression in activities during the preceding period of treatment. If the employer has an appropriate exercise facility on its premises the insurer may mandate use of that facility instead of providing a health club membership.
DWD 81.13(2)(c)
(c)
Computerized exercise programs. Computerized exercise programs utilize computer-controlled exercise equipment that allows for the isolation of specific muscle groups and the performance of graded exercise designed to increase strength, tone, flexibility, and range of motion. In combination with computerized range of motion or strength measuring tests, these programs allow for quantitative measurement of effort and progress.
DWD 81.13(2)(c)1.
1. `Indications.' The patient is deconditioned and requires a structured environment to accomplish rehabilitation goals. A health care provider shall document the reasons why reconditioning may not be accomplished with a home-based program of exercise.
DWD 81.13(2)(c)2.
2. `Guidelines.' The program shall have specific goals stated in objective terms, for example “improve strength of back extensors 50%." There shall be a specific set of prescribed activities and a specific timetable of progression in those activities, designed so that the goals may be achieved in the prescribed time. There shall be a prescribed frequency and duration of attendance.
DWD 81.13(2)(c)3.
3. `Treatment.' Treatment period is 6 weeks. Additional periods of treatment are not necessary unless there is documentation of attendance and progression in activities during the preceding period of treatment.
DWD 81.13(2)(d)
(d)
Work conditioning and work hardening programs. Work conditioning and work hardening programs are intensive, highly structured, job oriented, individualized treatment plans based on an assessment of the patient's work setting or job demands, and designed to maximize the patient's return to work. These programs shall include real or simulated work activities. Work conditioning is designed to restore an individual's neuromusculoskeletal strength, endurance, movement, flexibility, motor control, and cardiopulmonary function. Work conditioning uses physical conditioning and functional activities related to the individual's work. Services may be provided by one discipline of health care provider. Work hardening is designed to restore an individual's physical, behavioral, and vocational functions within an interdisciplinary model. Work hardening addresses the issues of productivity, safety, physical tolerances, and work behaviors. An interdisciplinary team includes professionals qualified to evaluate and treat behavioral, vocational, physical, and functional needs of the individual.
DWD 81.13(2)(d)1.
1. `Indications.' The patient is disabled from usual work and requires reconditioning for specific job tasks or activities and the reconditioning cannot be done on the job. A health care provider shall document the reasons why work hardening cannot be accomplished through a structured return to work program. Work conditioning is necessary when only physical and functional needs are identified. Work hardening is necessary when, in addition to physical and functional needs, behavioral, and vocational needs are also identified that are not otherwise being addressed.
DWD 81.13(2)(d)2.
2. `Guidelines.' The program shall have specific goals stated in terms of work activities, for example “able to type for 30 minutes." There shall be an individualized program of activities and the activities shall be chosen to simulate required work activities or to enable the patient to participate in simulated work activities. There shall be a specific timetable of progression in those activities, designed so that the goals may be achieved in the prescribed time. There shall be a set frequency and hours of attendance and the program shall maintain adequate documentation of attendance. There shall be a set duration of attendance. Activity restrictions shall be identified at completion of the program.
DWD 81.13(2)(d)3.
3. `Treatment.' The treatment period for a work conditioning or work hardening program is 6 weeks. Additional periods of treatment are not necessary unless there is documentation of attendance and progression in activities during the preceding period of treatment or unless there has been a change in the patient's targeted return to work job that necessitates a redesign of the program.
DWD 81.13(2)(e)
(e)
Chronic pain management programs. A chronic pain management program consists of a multidisciplinary team who provides coordinated, goal-oriented services to reduce pain, disability, improve functional status, promote return to work, and decrease dependence on the health system of persons with chronic pain syndrome. A pain management program shall provide physical rehabilitation, education on pain, relaxation training, psychosocial counseling, medical evaluation, and, if necessary, chemical dependency evaluation. The program of treatment shall be individualized and based on an organized evaluative process for screening and selecting patients. Treatment may be provided in an inpatient setting, outpatient setting, or both as appropriate.
DWD 81.13(2)(e)1.
1. `Indications.' The patient is diagnosed as having a chronic pain syndrome.
DWD 81.13(2)(e)2.
2. `Guidelines.' An admission evaluation shall be performed by a health care provider. The evaluation shall confirm the diagnosis of chronic pain syndrome and a willingness and ability of the patient to benefit from a pain management program. There shall be a specific set of prescribed activities and treatments and a specific timetable of progression in those activities. There shall be a set frequency and hours of attendance and the program shall maintain adequate documentation of attendance. There shall be a set duration of attendance.
DWD 81.13(2)(e)3.
3. `Treatment.' Treatment period is for initial treatment, a maximum of 20 eight-hour days, though fewer or shorter days may be used, and a maximum duration of 4 weeks no matter how many or how long the days prescribed. For aftercare, a maximum of 12 sessions is allowed. Only one completed pain management program is necessary for an injury.
DWD 81.13(2)(f)
(f)
Individual or group psychological or psychiatric counseling. DWD 81.13(2)(f)1.1. `Indications.' A personality or psychosocial evaluation has revealed one or more of the problems listed in
sub. (1) (a) that interfere with recovery from the physical injury, but the patient does not need or is not a candidate for a pain management program.
DWD 81.13(2)(f)2.
2. `Guidelines.' There shall be a specific set of goals based on the initial personality or psychosocial evaluation and a timetable for achieving those goals within the prescribed number of treatment or therapy sessions. There shall be a prescribed frequency of attendance and a treating health care provider shall maintain adequate documentation of attendance. There shall be a prescribed duration of treatment.
DWD 81.13(2)(f)3.
3. `Treatment.' Treatment period is a maximum of 12 sessions. Only one completed program of individual or group psychological or psychiatric counseling is necessary for an injury.
