Chapter DWD 81

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.

DWD 81.05(2)(d)4. 4. Suspected discitis.

DWD 81.05(2)(e) (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.

DWD 81.05(2)(f) (f) A health care provider may order myelography for any of the following:

DWD 81.05(2)(f)1. 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.

DWD 81.05(2)(f)2. 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.

DWD 81.05(2)(f)3. 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.

DWD 81.05(2)(g) (g) A health care provider may order computed tomography myelography for any of the following:

DWD 81.05(2)(g)1. 1. The patient’s condition is predominantly sciatica, there has been previous spinal surgery, and tumor is suspected.

DWD 81.05(2)(g)2. 2. The patient’s condition is predominantly sciatica, there has been previous spinal surgery, and magnetic resonance imaging scanning is equivocal.

DWD 81.05(2)(g)3. 3. When spinal stenosis is suspected and the computed tomography scanning or magnetic resonance imaging scanning is equivocal.

DWD 81.05(2)(g)4. 4. If there are progressive neurologic symptoms or changes and computed tomography scanning or magnetic resonance imaging scanning has been negative.

DWD 81.05(2)(g)5. 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.

DWD 81.05(2)(h) (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.

DWD 81.05(2)(i) (i) A health care provider may order enhanced magnetic resonance imaging scanning for any of the following:

DWD 81.05(2)(i)1. 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.

DWD 81.05(2)(i)2. 2. Hemorrhage is suspected.

DWD 81.05(2)(i)3. 3. Tumor or vascular malformation is suspected.

DWD 81.05(2)(i)4. 4. Infection or inflammatory disease is suspected.

DWD 81.05(2)(i)5. 5. Unenhanced magnetic resonance imaging scanning was equivocal.

DWD 81.05(2)(j) (j) A health care provider may order discography for any of the following:

DWD 81.05(2)(j)1. 1. All of the following are present:

DWD 81.05(2)(j)1.a. a. Back pain is the predominant complaint.

DWD 81.05(2)(j)1.b. b. The patient has failed to improve with initial nonsurgical management.

DWD 81.05(2)(j)1.c. c. Other imaging has not established a diagnosis.

DWD 81.05(2)(j)1.d. d. Lumbar fusion surgery or other surgical procedures are being considered as a therapy.

DWD 81.05(2)(j)2. 2. There has been previous spinal surgery, and pseudoarthrosis, recurrent disc herniation, annular tear, or internal disc disruption is suspected.

DWD 81.05(2)(k) (k) A health care provider may order computed tomography discography when it is necessary to view the morphology of a disc.

DWD 81.05(2)(L) (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.

DWD 81.05(2)(m) (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).

DWD 81.05(2)(n) (n) A health care provider may order anterior-posterior and lateral X-rays of the lumbosacral spine for any of the following:

DWD 81.05(2)(n)1. 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.

DWD 81.05(2)(n)2. 2. When the history, signs, symptoms, or laboratory studies indicate possible tumor, infection, or inflammatory lesion.

DWD 81.05(2)(n)3. 3. For postoperative follow-up of lumbar fusion surgery.

DWD 81.05(2)(n)4. 4. When the patient is more than 50 years of age.

DWD 81.05(2)(n)5. 5. Before beginning a course of treatment with spinal adjustment or manipulation.

DWD 81.05(2)(n)6. 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.

DWD 81.05(2)(o) (o) A health care provider may not order anterior-posterior and lateral X-rays of the lumbosacral spine for any of the following:

DWD 81.05(2)(o)1. 1. To verify progress during initial nonsurgical treatment.

DWD 81.05(2)(o)2. 2. To evaluate a successful initial nonsurgical treatment program.

DWD 81.05(2)(p) (p) A health care provider may order oblique X-rays of the lumbosacral spine for any of the following:

DWD 81.05(2)(p)1. 1. To follow up abnormalities detected on anterior-posterior or lateral X-ray.

DWD 81.05(2)(p)2. 2. For postoperative follow-up of lumbar fusion surgery.

DWD 81.05(2)(p)3. 3. To follow up spondylolysis or spondylolisthesis not adequately diagnosed by other necessary imaging procedures.

DWD 81.05(2)(q) (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.

DWD 81.05(2)(r) (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).

DWD 81.05 History History: CR 07-019: cr. Register October 2007 No. 622, eff. 11-1-07.

DWD 81.06 DWD 81.06 Low back pain.

DWD 81.06(1) (1) Diagnostic procedures for the evaluation of low back pain.

DWD 81.06(1)(a) (a) A health care provider shall determine the nature of the low back condition before initiating treatment.

DWD 81.06(1)(b) (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.

DWD 81.06(1)(b)1. 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.

DWD 81.06(1)(b)2. 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.

DWD 81.06(1)(b)3. 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.

DWD 81.06(1)(b)4. 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.

DWD 81.06(1)(c) (c) A health care provider may not order laboratory tests in the evaluation of a patient with regional low back pain, radicular pain, or cauda equina syndrome, except for any of the following:

DWD 81.06(1)(c)1. 1. When a patient’s history, age, or examination suggests infection, metabolic-endocrinologic disorders, tumorous conditions, systemic musculoskeletal disorders, such as rheumatoid arthritis or ankylosing spondylitis.

DWD 81.06(1)(c)2. 2. To evaluate potential adverse side effects of medications.

DWD 81.06(1)(c)3. 3. As part of a preoperative evaluation.

DWD 81.06(1)(d) (d) Laboratory tests may be ordered any time a health care provider suspects any of the conditions in par. (c), if the health care provider justifies the need for the tests ordered with clear documentation of the indications.

DWD 81.06(1)(e) (e) Medical imaging evaluation of the lumbosacral spine shall be based on the findings of the history and physical examination and may not be ordered before a health care provider’s clinical evaluation of the patient. Medical imaging may not be performed as a routine procedure and shall comply with all of the guidelines in s. DWD 81.05 (1) and (2). A health care provider shall document the appropriate indications for any medical imaging studies obtained.

DWD 81.06(1)(f) (f) A health care provider may not order electromyography and nerve conduction studies for regional low back pain as defined in s. DWD 81.06 (1) (b) 1. A health care provider may order electromyography and nerve conduction studies as a diagnostic tool for radicular pain and cauda equina syndrome as defined in s. DWD 81.06 (1) (b) 2. to 4. after the first 3 weeks of radicular symptoms. Repeat electromyography and nerve conduction studies for radicular pain and cauda equina syndrome are not necessary unless a new neurologic symptom or progression of existing finding has developed that in itself would warrant electrodiagnostic testing. Failure to improve with treatment is not an indication for repeat testing.

DWD 81.06(1)(g) (g) A health care provider may not order the use of any of the following procedures or tests for the diagnosis of any of the clinical categories in par. (b) 1. to 4.:

DWD 81.06(1)(g)1. 1. Surface electromyography or surface paraspinal electromyography.

DWD 81.06(1)(g)2. 2. Thermography.

DWD 81.06(1)(g)3. 3. Plethysmography.

DWD 81.06(1)(g)4. 4. Electronic X-ray analysis of plain radiographs.

DWD 81.06(1)(g)5. 5. Diagnostic ultrasound of the lumbar spine.

DWD 81.06(1)(g)6. 6. Somatosensory evoked potentials and motor evoked potentials.

DWD 81.06(1)(h) (h) A health care provider may not order computerized range of motion or strength measuring tests during the period of initial nonsurgical management but may order these tests during the period of chronic management when used in conjunction with a computerized exercise program, work hardening program, or work conditioning program. During the period of initial nonsurgical management, computerized range of motion or strength testing may be performed but shall be done in conjunction with an office visit with a health care provider’s evaluation or treatment, or physical or occupational therapy evaluation or treatment.

DWD 81.06(1)(i) (i) A health care provider may order personality or psychosocial evaluations for evaluating patients who continue to have problems despite appropriate care. 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, the health care provider performing the evaluation shall consider all of the following:

DWD 81.06(1)(i)1. 1. Is symptom magnification occurring?

DWD 81.06(1)(i)2. 2. Does the patient exhibit an emotional reaction to the injury, such as depression, fear, or anger, that is interfering with recovery?

DWD 81.06(1)(i)3. 3. Are there other personality factors or disorders that are interfering with recovery?