Wisconsin Legislature: DWD 81.05(2)(b)3.

(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.

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

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.

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.

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.

(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.

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

DWD 81.05 Guidelines for medical imaging.

(1) General principles.

(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:

(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).

(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.

(d) Routine imaging. Imaging on a routine basis is not necessary unless the information from the study is necessary to develop a treatment plan.

(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:

1. To diagnose a suspected fracture or suspected dislocation.

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.

3. To follow up a surgical procedure.

4. To diagnose a change in the patient’s condition marked by new or altered physical findings.

5. To evaluate a new episode of injury or exacerbation that in itself warrants an imaging study.

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.

(f) Alternative imaging.

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.

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.

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.

(2) Specific imaging procedures for low back pain.

(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.

(b) A health care provider may order computed tomography scanning for any of the following:

1. When cauda equina syndrome is suspected.

2. For evaluation of progressive neurologic deficit.

3. When bony lesion is suspected on the basis of other tests or imaging procedures.

(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.

(d) A health care provider may order magnetic resonance imaging scanning for any of the following:

1. When cauda equina syndrome is suspected.

2. For evaluation of progressive neurologic deficit.

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.

4. Suspected discitis.

(e) Except as specified in par. (d), a health care provider may not order magnetic resonance imaging scanning in the first 4 weeks after an injury. Magnetic resonance imaging 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.

(f) A health care provider may order myelography for any of the following:

1. Myelography may be substituted for otherwise necessary computed tomography scanning or magnetic resonance imaging scanning in accordance with pars. (b) and (d), if those imaging modalities are not locally available.

2. In addition to computed tomography scanning or magnetic resonance imaging scanning, if there are progressive neurologic deficits or changes and computed tomography scanning or magnetic resonance imaging scanning has been negative.

3. For preoperative evaluation in cases of surgical intervention, but only if computed tomography scanning or magnetic resonance imaging scanning have failed to provide a definite preoperative diagnosis.

(g) A health care provider may order computed tomography myelography for any of the following:

1. The patient’s condition is predominantly sciatica, there has been previous spinal surgery, and tumor is suspected.

2. The patient’s condition is predominantly sciatica, there has been previous spinal surgery, and magnetic resonance imaging scanning is equivocal.

3. When spinal stenosis is suspected and the computed tomography scanning or magnetic resonance imaging scanning is equivocal.

4. If there are progressive neurologic symptoms or changes and computed tomography scanning or magnetic resonance imaging scanning has been negative.

5. For preoperative evaluation in cases of surgical intervention, but only if computed tomography scanning or magnetic resonance imaging scanning have failed to provide a definite preoperative diagnosis.

(h) A health care provider may order intravenous enhanced computed tomography scanning only if there has been previous spinal surgery, and the imaging study is being used to differentiate scar due to previous surgery from disc herniation or tumor, but only if intrathecal contrast for computed tomography-myelography is contraindicated and magnetic resonance imaging scanning is not available or is also contraindicated.

(i) A health care provider may order enhanced magnetic resonance imaging scanning for any of the following:

1. There has been previous spinal surgery, and the imaging study is being used to differentiate scar due to previous surgery from disc herniation or tumor.

2. Hemorrhage is suspected.

3. Tumor or vascular malformation is suspected.

4. Infection or inflammatory disease is suspected.

5. Unenhanced magnetic resonance imaging scanning was equivocal.

(j) A health care provider may order discography for any of the following:

1. All of the following are present:

a. Back pain is the predominant complaint.

b. The patient has failed to improve with initial nonsurgical management.

c. Other imaging has not established a diagnosis.

d. Lumbar fusion surgery or other surgical procedures are being considered as a therapy.

2. There has been previous spinal surgery, and pseudoarthrosis, recurrent disc herniation, annular tear, or internal disc disruption is suspected.

(k) A health care provider may order computed tomography discography when it is necessary to view the morphology of a disc.

(L) A health care provider may not order nuclear isotope imaging including technicium, indium, and gallium scans, unless tumor, stress fracture, infection, avascular necrosis, or inflammatory lesion is suspected on the basis of history, physical examination findings, laboratory studies, or the results of other imaging studies.

(m) A health care provider may not order thermography for the diagnosis of any of the clinical categories of low back conditions in s. DWD 81.06 (1) (b).

(n) A health care provider may order anterior-posterior and lateral X-rays of the lumbosacral spine for any of the following:

1. When there is a history of significant acute trauma as the precipitating event of the patient’s condition, and fracture, dislocation, or fracture dislocation is suspected.

2. When the history, signs, symptoms, or laboratory studies indicate possible tumor, infection, or inflammatory lesion.

3. For postoperative follow-up of lumbar fusion surgery.

4. When the patient is more than 50 years of age.

5. Before beginning a course of treatment with spinal adjustment or manipulation.

6. Eight weeks after an injury 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.

(o) A health care provider may not order anterior-posterior and lateral X-rays of the lumbosacral spine for any of the following:

1. To verify progress during initial nonsurgical treatment.

2. To evaluate a successful initial nonsurgical treatment program.

(p) A health care provider may order oblique X-rays of the lumbosacral spine for any of the following:

1. To follow up abnormalities detected on anterior-posterior or lateral X-ray.

2. For postoperative follow-up of lumbar fusion surgery.

3. To follow up spondylolysis or spondylolisthesis not adequately diagnosed by other necessary imaging procedures.

(q) A health care provider may not order oblique X-rays of the lumbosacral spine as part of a package of X-rays including anterior-posterior and lateral X-rays of the lumbosacral spine.

(r) A health care provider may not order electronic X-ray analysis of plain radiographs and diagnostic ultrasound of the lumbar spine for diagnosis of any of the low back conditions in s. DWD 81.06 (1) (b).

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

DWD 81.06 Low back pain.

(1) Diagnostic procedures for the evaluation of low back pain.

(a) A health care provider shall determine the nature of the low back condition before initiating treatment.

(b) A health care provider shall perform and document an appropriate history and physical examination. Based on the history and physical examination the health care provider shall assign the patient at each visit to the appropriate clinical category under subds. 1. to 4. The health care provider shall document the diagnosis in the medical record. For the purposes of subds. 2. and 3., “radicular pain” means pain radiating distal to the knee, or pain conforming to a dermatomal distribution, and accompanied by anatomically congruent motor weakness, or reflex changes. This section does not apply to fractures of the lumbar spine, or low back pain due to an infectious, immunologic, metabolic, endocrine, neurologic, visceral, or neoplastic disease process.

1. Regional low back pain, includes referred pain to the leg above the knee unless it conforms to an L2, L3, or L4 dermatomal distribution and is accompanied by anatomically congruent motor weakness or reflex changes. Regional low back pain includes the diagnoses of lumbar, lumbosacral, or sacroiliac strain, sprain, myofascial syndrome, musculoligamentous injury, soft tissue injury, spondylosis, and other diagnoses for pain believed to originate in the discs, ligaments, muscles, or other soft tissues of the lumbar spine or sacroiliac joints and that effects the lumbosacral region, with or without referral to the buttocks or leg, or both above the knee, including ICD-9-CM codes 720 to 720.9, 721, 721.3, 721.5 to 721.90, 722, 722.3, 722.32, 722.5, 722.51, 722.52, 722.6, 722.9, 722.90, 722.93, 724.2, 724.5, 724.6, 724.8, 724.9, 732.0, 737 to 737.9, 738.4, 738.5, 739.2 to 739.4, 756.1 to 756.19, 847.2 to 847.9, 922.3, 926.1, 926.11, and 926.12.

2. Radicular pain, with or without regional low back pain, with static or no neurologic deficit. This includes the diagnoses of sciatica; lumbar or lumbosacral radiculopathy, radiculitis, or neuritis; displacement or herniation of intervertebral disc with myelopathy, radiculopathy, radiculitis, or neuritis; spinal stenosis with myelopathy, radiculopathy, radiculitis, or neuritis; and any other diagnoses for pain in the leg below the knee believed to originate with irritation of a nerve root in the lumbar spine, including ICD-9-CM codes 721.4, 721.42 721.91, 722.1, 722.10, 722.2, 722.7, 722.73, 724.0, 724.00, 724.02, 724.09, 724.3, 724.4, and 724.9. In these cases, neurologic findings on history and physical examination are either absent or do not show progressive deterioration.

3. Radicular pain, with or without regional low back pain, with progressive neurologic deficit. This includes the same diagnoses as subd. 2., except this subdivision applies when there is a history of progressive deterioration in the neurologic symptoms and physical findings which include worsening sensory loss, increasing muscle weakness, or progressive reflex changes.

4. Cauda equina syndrome, which is a syndrome characterized by anesthesia in the buttocks, genitalia, or thigh and accompanied by disturbed bowel and bladder function, including ICD-9-CM codes 344.6, 344.60, and 344.61.