Chapter DWD 81

DWD 81.05   Guidelines for medical imaging.

DWD 81.06   Low back pain.

DWD 81.07   Neck pain.

DWD 81.08   Thoracic back pain.

DWD 81.09   Upper extremity disorders.

DWD 81.10   Complex regional pain syndrome of the upper and lower extremities.

DWD 81.11   Inpatient hospitalization guidelines.

DWD 81.12   Guidelines for surgical procedures.

DWD 81.13   Chronic management.

DWD 81.14   Health care provider advisory committee.

DWD 81.01 DWD 81.01 Purpose and application.

DWD 81.01(1) (1) Purpose.

DWD 81.01(1)(a) (a) The purpose of this chapter is to establish guidelines for necessary and appropriate treatment of patients with compensable worker’s compensation injuries under s. 102.16 (2m), Stats., and s. DWD 80.73.

DWD 81.01(1)(b) (b) The guidelines contained in this chapter are factors for an impartial health care services review organization and a member from an independent panel of experts established by the department to consider in rendering opinions to resolve necessity of treatment disputes arising under s. 102.16 (2m), Stats., and s. DWD 80.73.

DWD 81.01(1)(c) (c) Sections DWD 81.01 to 81.13 do not affect any determination of liability for an injury under ch. 102, Stats., and are not intended to expand or restrict a health care provider’s scope of practice under any other statute.

DWD 81.01(2) (2) Application. All treatment shall be medically necessary as defined in s. DWD 81.03 (10). In the absence of a specific guideline any applicable general guidelines govern. A departure from a guideline that limits the duration or type of treatment may be appropriate in any of the circumstances specified in s. DWD 81.04 (5). All limitations on the duration of a specific treatment modality or type of modality begin with the first time the modality is initiated after November 1, 2007. This chapter does not apply to treatment of an injury after an insurer has denied liability for the injury, except in cases in which the guidelines apply to treatment initiated after liability has been established.

DWD 81.01 History History: CR 07-019: cr. Register October 2007 No. 622, eff. 11-1-07.

DWD 81.02 DWD 81.02 Incorporation by reference. The ICD-9-CM diagnostic codes referenced in this chapter are contained in the fourth edition of the International Classification of Diseases, Clinical Modification, 9th Revision, 1994, and corresponding annual updates. This document is incorporated by reference.

DWD 81.02 Note Note: This volume is published by the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services, and may be purchased through the Superintendent of Documents, United States Government Printing Office, Washington, D.C. 20402. It is on file at the Worker’s Compensation Division of the Department of Workforce Development and at the office of the Legislative Reference Bureau.

DWD 81.02 History History: CR 07-019: cr. Register October 2007 No. 622, eff. 11-1-07.

DWD 81.03 DWD 81.03 Definitions. Unless otherwise provided, in this chapter:

DWD 81.03(1) (1) “Active treatment” means treatment specified in ss. DWD 81.06 (4), 81.07 (4), 81.08 (4), 81.09 (4), and 81.10 (2) that requires active patient participation in a therapeutic program to increase flexibility, strength, endurance, or awareness of proper body mechanics.

DWD 81.03(2) (2) “Chronic pain” means complaint of persistent pain beyond 12 weeks of appropriate treatment provided under this chapter. It is persistent with verbal and nonverbal pain behaviors that exceed the identifiable pathology and medical condition. It is pain that interferes with physical, psychological, social, or vocational functioning.

DWD 81.03(3) (3) “Condition” means the symptoms, physical signs, clinical findings, and functional status that characterize a person’s complaint, illness, or injury related to a current claim for compensation.

DWD 81.03(4) (4) “Day” means calendar day.

DWD 81.03(5) (5) “Emergency treatment” means treatment that is required for the immediate diagnosis and treatment of a medical condition that, if not immediately diagnosed and treated, could lead to serious physical or mental disability or death, or is immediately necessary to alleviate severe pain. Emergency treatment includes treatment delivered in response to symptoms that may or may not represent an actual emergency but that is necessary to determine whether an emergency exists.

DWD 81.03(6) (6) “Etiology” means the anatomic alteration, physiologic dysfunction, or other biological or psychological abnormality that is considered a cause of the patient’s condition.

DWD 81.03(7) (7) “Functional status” means the ability of an individual to engage in activities of daily living and other social, recreational, and vocational activities.

DWD 81.03(8) (8) “Initial nonsurgical management or treatment” is initial treatment provided after an injury that includes passive treatment, active treatment, injections, and durable medical equipment under ss. DWD 81.06 (3), (4), (5), and (8), 81.07 (3), (4), (5), and (8), 81.08 (3), (4), (5), and (8), 81.09 (3), (4), (5), and (8), and 81.10 (2). Scheduled and nonscheduled medication may be a part of initial nonsurgical treatment. Initial nonsurgical management does not include surgery or chronic management modalities under s. DWD 81.13.

DWD 81.03(9) (9) “Medical imaging procedure” is a technique, process, or technology used to create a visual image of the body or its function. Medical imaging includes X-rays, tomography, angiography, venography, myelography, computed tomography scanning, magnetic resonance imaging scanning, ultrasound imaging, nuclear isotope imaging, positron emission tomography scanning, and thermography.

DWD 81.03(10) (10) “Medically necessary treatment” means those health services for a compensable injury that are reasonable and necessary for the diagnosis and to cure or relieve a condition consistent with any applicable treatment guidelines in this chapter. If ss. DWD 81.04 to 81.13 do not apply, the treatment must be reasonable and necessary for the diagnosis and to cure or relieve a condition consistent with the current accepted standards of practice within the scope of the provider’s license or certification.

DWD 81.03(11) (11) “Neurologic deficit” means a loss of function secondary to involvement of the central or peripheral nervous system. This includes motor loss; spasticity; loss of reflex; radicular or anatomic sensory loss; loss of bowel, bladder or erectile function; impairment of special senses, including vision, hearing, taste, or smell; or deficits in cognitive or memory function.

DWD 81.03(12) (12) “Progressive neurologic deficit” means any neurologic deficit that has become worse by history or been noted by repeated examination since onset.

DWD 81.03(13) (13) “Passive treatment” is any treatment modality specified in ss. DWD 81.06 (3), 81.07 (3), 81.08 (3), 81.09 (3), and 81.10 (2). Passive treatment modalities include bedrest, thermal treatment, traction, acupuncture, electrical muscle stimulation, braces, manual and mechanical therapy, massage, and adjustments.

DWD 81.03(14) (14) “Static neurologic deficit” means any neurologic deficit that has remained the same by history or been noted by repeated examination since onset.

DWD 81.03(15) (15) “Therapeutic injection” is any injection modality specified in ss. DWD 81.06 (5), 81.07 (5), 81.08 (5), 81.09 (5), and 81.10 (2). Therapeutic injections include trigger point injections, sacroiliac injections, facet joint injections, facet nerve blocks, nerve root blocks, epidural injections, soft tissue injections, peripheral nerve blocks, injections for peripheral nerve entrapment, and sympathetic blocks.

DWD 81.03(16) (16) “Week” means calendar week.

DWD 81.03 History History: CR 07-019: cr. Register October 2007 No. 622, eff. 11-1-07.

DWD 81.04 DWD 81.04 General treatment guidelines; excessive treatment.

DWD 81.04(1) (1) General.

DWD 81.04(1)(a) (a) All treatment shall be medically necessary treatment. A health care provider shall evaluate the medical necessity of all treatment under par. (b) on an ongoing basis. This chapter does not require or permit any more frequent examinations than would normally be required for the condition being treated but may require ongoing evaluation of the patient that is medically necessary and consistent with accepted medical practice.

DWD 81.04(1)(b) (b) The health care provider shall evaluate at each visit whether initial nonsurgical treatment for the low back, cervical, thoracic, and upper extremity conditions specified in ss. DWD 81.06 to 81.09 is effective according to subds. 1. to 3. No later than any applicable treatment response time in ss. DWD 81.06 to 81.09, the health care provider shall evaluate whether the passive, active, injection, or medication treatment modality is resulting in progressive improvement as specified in all of the following:

DWD 81.04(1)(b)1. 1. 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 81.04(1)(b)2. 2. 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 81.04(1)(b)3. 3. The patient’s functional status, especially vocational activities, is progressively improving, as evidenced by documentation in the medical record or successive reports of work ability of less restrictive limitations on activity.

DWD 81.04(1)(c) (c) Except as otherwise provided under ss. DWD 81.06 (3) (b), 81.07 (3) (b), 81.08 (3) (b), and 81.09 (3) (b), if there is not progressive improvement in at least 2 criteria of par. (b) 1. to 3., the modality shall be discontinued or significantly modified, or the health care provider shall reconsider the diagnosis. The evaluation of the effectiveness of the treatment modality may be delegated to an allied health professional directly providing the treatment.

DWD 81.04(1)(d) (d) The health care provider shall use the least intensive setting appropriate and shall assist the patient in becoming independent in the patient’s own care to the extent possible so that prolonged or repeated use of health care providers and medical facilities is minimized.

DWD 81.04(2) (2) Documentation. A health care provider shall maintain an appropriate record of any treatment provided to a patient. An appropriate record is a legible health care service record or report that substantiates the nature and necessity of a health care service being billed and its relationship to the work injury.

DWD 81.04(3) (3) Nonoperative treatment. A health care provider shall provide a trial of nonoperative treatment before offering or performing surgical treatment unless the treatment for the condition requires immediate surgery, unless an emergency situation exists, or unless the accepted standard of initial treatment for the condition is surgery.

DWD 81.04(4) (4) Chemical dependency. A health care provider shall maintain diligence to detect incipient or actual chemical dependency to any medication prescribed for treatment of the patient’s condition. In cases of incipient or actual dependency, the health care provider shall refer the patient for appropriate evaluation and treatment of the dependency.

DWD 81.04(5) (5) Departure from guidelines. A health care provider’s departure from a guideline that limits the duration or type of treatment in this chapter may be appropriate in any of the following circumstances:

DWD 81.04(5)(a) (a) There is a documented medical complication.

DWD 81.04(5)(b) (b) Previous treatment did not meet the accepted standard of practice and meet the guidelines in this chapter for the health care provider who ordered the treatment.

DWD 81.04(5)(c) (c) The treatment is necessary to assist the patient in the initial return to work where the patient’s work activities place stress on the part of the body affected by the work injury. The health care provider shall document in the medical record the specific work activities that place stress on the affected body part, the details of the treatment plan, and treatment delivered on each visit, the patient’s response to the treatment, and efforts to promote patient independence in the patient’s own care to the extent possible so that prolonged or repeated use of health care providers and medical facilities is minimized.

DWD 81.04(5)(d) (d) The treatment continues to meet 2 of the following 3 criteria, as documented in the medical record:

DWD 81.04(5)(d)1. 1. The patient’s subjective complaints of pain are progressively improving as evidenced by documentation in the medical record of decreased distribution, frequency, or intensity of symptoms.

DWD 81.04(5)(d)2. 2. The patient’s 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 81.04(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.