Chapter DWD 81

DWD 81.07(11)(a) (a) A health care provider shall use initial nonsurgical treatment for the first phase of treatment for all patients with regional neck pain under sub. (1) (b) 1.

DWD 81.07(11)(a)1. 1. The active, passive, injection, durable medical equipment, and medication treatment modalities and procedures in subs. (3), (4), (5), (8), and (10), may be used in sequence or simultaneously during the period of initial nonsurgical management depending on the severity of the condition.

DWD 81.07(11)(a)2. 2. The only therapeutic injections necessary for patients with regional neck pain are trigger point injections, facet joint injections, facet nerve blocks, and epidural blocks, and their use must meet the guidelines of sub. (5).

DWD 81.07(11)(a)3. 3. After the first week of treatment, initial nonsurgical treatment shall at all times contain active treatment modalities according to the guidelines of sub. (4).

DWD 81.07(11)(a)4. 4. Initial nonsurgical treatment shall be provided in the least intensive setting consistent with quality health care practices.

DWD 81.07(11)(a)5. 5. Except as otherwise provided in sub. (3), passive treatment modalities in a clinic setting or requiring attendance by a health care provider are not necessary beyond 12 weeks after any passive modality other than bedrest or bracing is first initiated.

DWD 81.07(11)(b) (b) Surgical evaluation or chronic management is necessary if the patient continues with symptoms and physical findings after the course of initial nonsurgical management and if the patient’s condition prevents the resumption of the regular activities of daily life, including regular vocational activities. The purpose of surgical evaluation is to determine whether surgery is necessary in the treatment of a patient who has failed to recover with initial nonsurgical care. If the patient is not a surgical candidate, then chronic management is necessary.

DWD 81.07(11)(b)1. 1. Surgical evaluation if necessary may begin as soon as 8 weeks after, but shall begin no later than 12 weeks after, beginning initial nonsurgical management. An initial recommendation or decision against surgery does not preclude surgery at a later date.

DWD 81.07(11)(b)2. 2. Surgical evaluation may include the use of appropriate medical imaging techniques. The imaging technique shall be chosen on the basis of the suspected etiology of the patient’s condition but a health care provider shall follow the guidelines of s. DWD 81.05. Medical imaging studies that do not meet these guidelines are not necessary.

DWD 81.07(11)(b)3. 3. Surgical evaluation may also include diagnostic blocks and injections. These blocks and injections are only necessary if their use is consistent with the guidelines of sub. (1) (j).

DWD 81.07(11)(b)4. 4. Surgical evaluation may also include personality or psychosocial evaluation, consistent with the guidelines of sub. (1) (i).

DWD 81.07(11)(b)5. 5. Consultation with other health care providers may be appropriate as part of the surgical evaluation. The need for consultation and the choice of consultant will be determined by the findings on medical imaging, diagnostic analgesic blocks, and injections, if performed, and the patient’s ongoing subjective complaints and physical findings.

DWD 81.07(11)(b)6. 6. The only surgical procedure necessary for patients with regional neck pain only is cervical arthrodesis, with or without instrumentation, which shall meet the guidelines in sub. (6). For patients with failed surgery, spinal cord stimulators or intrathecal drug delivery systems may be necessary consistent with the guidelines of sub. (6) (d).

DWD 81.07(11)(b)6.a. a. If surgery is necessary, it shall be offered to the patient as soon as possible. If the patient agrees to the proposed surgery, it shall be performed as expeditiously as possible, consistent with sound medical practice.

DWD 81.07(11)(b)6.b. b. If surgery is not necessary or if the patient does not wish to proceed with surgical therapy, then the patient is a candidate for chronic management.

DWD 81.07(11)(c) (c) If the patient continues with symptoms and objective physical findings after surgery has been rendered or the patient refuses surgery or the patient was not a candidate for surgery, 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 under s. DWD 81.13.

DWD 81.07(12) (12) Specific treatment guidelines for radicular pain, with or without regional neck pain, with no or static neurologic deficits.

DWD 81.07(12)(a) (a) Initial nonsurgical treatment is appropriate for all patients with radicular pain, with or without regional neck pain, with no or static neurologic deficits under sub. (1) (b) 2., and shall be the first phase of treatment. It shall be provided within the guidelines of sub. (11) (a), with the following modifications: Epidural blocks, nerve root, and peripheral nerve blocks are the only therapeutic injections necessary for patients with radicular pain only. If there is a component of regional neck pain, therapeutic facet joint injections, facet nerve blocks, and trigger point injections may also be necessary.

DWD 81.07(12)(b) (b) Surgical evaluation or chronic management is necessary 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. It shall be provided within the guidelines of sub. (11) (b), with the following modifications: The only surgical procedures necessary for patients with radicular pain are decompression of a cervical nerve root which shall meet the guidelines of sub. (6) and s. DWD 81.12 (1) (c) and cervical arthrodesis, with or without instrumentation. For patients with failed surgery, spinal cord stimulators or intrathecal drug delivery systems may be necessary consistent with sub. (6) (d).

DWD 81.07(12)(c) (c) If the patient continues with symptoms and objective physical findings after surgical therapy has been rendered or the patient refused surgical therapy or the patient was not a candidate for surgical therapy, 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. Any course or program of chronic management for patients with radicular pain, with or without regional neck pain, with static neurologic changes shall be provided under the guidelines of s. DWD 81.13.

DWD 81.07(13) (13) Specific treatment guidelines for radicular pain, with or without regional neck pain, with progressive neurologic deficits.

DWD 81.07(13)(a) (a) Patients with radicular pain, with or without regional neck pain, with progressive neurologic deficits may require immediate or emergency evaluation at any time during the course of their overall treatment. A health care provider may make the decision to proceed with surgical evaluation based on the type of neurologic changes observed, the severity of the changes, the rate of progression of the changes, and the response to any nonsurgical treatments. Surgery, if necessary, may be performed at any time during the course of treatment. Surgical evaluation and surgery shall be provided within the guidelines of sub. (11) (b), with the following modifications:

DWD 81.07(13)(a)1. 1. Surgical evaluation and surgical therapy may begin at any time.

DWD 81.07(13)(a)2. 2. The only surgical procedures necessary for patients with radicular pain are decompression of a cervical nerve root that shall meet the guidelines of sub. (6) and s. DWD 81.12 (1) (c), or cervical arthrodesis, with or without instrumentation. For patients with failed back surgery, spinal cord stimulators or intrathecal drug delivery systems may be necessary consistent with the guidelines of sub. (6) (d).

DWD 81.07(13)(b) (b) If a health care provider decides to proceed with a course of nonsurgical care for a patient with radicular pain with progressive neurologic changes, it shall follow the guidelines of sub. (12) (a).

DWD 81.07(13)(c) (c) If the patient continues with symptoms and objective physical findings after surgical therapy has been rendered or the patient refuses surgical therapy or the patient was not a candidate for surgical therapy, 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. Any course or program of chronic management for patients with radicular pain, with or without regional neck pain, with progressive neurologic changes at first presentation shall be provided under the guidelines of s. DWD 81.13.

DWD 81.07(14) (14) Specific treatment guidelines for myelopathy.

DWD 81.07(14)(a) (a) Patients with myelopathy may require emergency surgical evaluation at any time during the course of their overall treatment. A health care provider may make the decision to proceed with surgical evaluation based on the type of neurologic changes observed, the severity of the changes, the rate of progression of the changes, and the response to any nonsurgical treatments. Surgery, if necessary, may be performed at any time during the course of treatment. Surgical evaluation and surgery shall be provided within the guidelines of sub. (6) (b), with the following modifications:

DWD 81.07(14)(a)1. 1. Surgical evaluation and surgical therapy may begin at any time.

DWD 81.07(14)(a)2. 2. The only surgical procedures necessary for patients with myelopathy are anterior or posterior decompression of the spinal cord, or cervical arthrodesis with or without instrumentation. For patients with failed back surgery, spinal cord stimulators or intrathecal drug delivery systems may be necessary consistent with the guidelines of sub. (6) (d).

DWD 81.07(14)(b) (b) If a health care provider decides to proceed with a course of nonsurgical care for a patient with myelopathy, it shall follow the guidelines of sub. (12) (a).

DWD 81.07(14)(c) (c) If the patient continues with symptoms and objective physical findings after surgical therapy has been rendered or the patient refuses surgical therapy or the patient was not a candidate for surgical therapy, 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. Any course or program of chronic management for patients with myelopathy shall be provided under the guidelines of s. DWD 81.13.

DWD 81.07 History History: CR 07-019: cr. Register October 2007 No. 622, eff. 11-1-07.

DWD 81.08 DWD 81.08 Thoracic back pain.

DWD 81.08(1) (1) Diagnostic procedures for treatment of thoracic back injury.

DWD 81.08(1)(a) (a) A health care provider shall determine the nature of the thoracic back condition before initiating treatment.

DWD 81.08(1)(b) (b) A health care provider shall perform and document an appropriate history and physical examination. Based on the history and physical examination, a health care provider shall assign the patient at each visit to the appropriate clinical category in subds. 1. to 3. A health care provider shall document the diagnosis in the medical record. For the purposes of subds. 2. and 3., “radicular pain” means pain radiating in a dermatomal distribution around the chest or abdomen. This section does not apply to fractures of the thoracic spine or thoracic back pain due to an infectious, immunologic, metabolic, endocrine, neurologic, visceral, or neoplastic disease process.

DWD 81.08(1)(b)1. 1. Regional thoracic back pain includes the diagnoses of thoracic strain, sprain, myofascial syndrome, musculoligamentous injury, soft tissue injury, and any other diagnosis for pain believed to originate in the discs, ligaments, muscles, or other soft tissues of the thoracic spine and that affects the thoracic region, including ICD-9-CM codes 720 to 720.9, 721 to 721.0, 721.5 to 721.90, 722.3 to 722.30, 722.4, 722.6, 722.9 to 722.91, 723 to 723.3, 723.5 to 723.9, 724.5, 724.8, 724.9, 732.0, 737 to 737.9, 738.4, 738.5, 739.1, 756.1 to 756.19, 847 to 847.0, 920, 922.3, 925, and 926.1 to 926.12.

DWD 81.08(1)(b)2. 2. Radicular pain, with or without regional thoracic back pain, includes the diagnoses of thoracic radiculopathy, radiculitis, or neuritis; displacement or herniation of intervertebral disc with radiculopathy, radiculitis, or neuritis; spinal stenosis with radiculopathy, radiculitis, or neuritis; and any other diagnoses for pain believed to originate with irritation of a nerve root in the thoracic spine, including ICD-9-CM codes 721.1, 721.91, 722 to 722.0, 722.2, 722.7 to 722.71, 723.4, and 724 to 724.00.

DWD 81.08(1)(b)3. 3. Thoracic compressive myelopathy, with or without radicular pain, is a condition characterized by weakness and spasticity in one or both legs and associated with any of the following: exaggerated reflexes, an extensor plantar response, bowel or bladder dysfunction, sensory ataxia, or bilateral sensory changes.

DWD 81.08(1)(c) (c) A health care provider may not order laboratory tests in the evaluation of a patient with regional thoracic back pain, or radicular pain, except for any of the following:

DWD 81.08(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 81.08(1)(c)2. 2. To evaluate potential adverse side effects of medications.

DWD 81.08(1)(c)3. 3. As part of a preoperative evaluation.

DWD 81.08(1)(d) (d) Laboratory tests may be ordered at any time a health care provider suspects any of the conditions specified in par. (c), but a health care provider shall justify the need for the tests ordered with clear documentation of the indications.

DWD 81.08(1)(e) (e) Medical imaging evaluation of the thoracic spine shall be based on the findings of the history and physical examination and may not be ordered prior to a health care provider’s clinical evaluation of the patient. Medical imaging may not be performed as a routine procedure and shall comply with the guidelines in s. DWD 81.05. A health care provider shall document the appropriate indications for any medical imaging studies obtained.

DWD 81.08(1)(f) (f) A health care provider may not order electromyography and nerve conduction studies for regional thoracic back pain and radicular pain under par. (b) 1. to 3.

DWD 81.08(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 3.:

DWD 81.08(1)(g)1. 1. Surface electromyography or surface paraspinal electromyography.

DWD 81.08(1)(g)2. 2. Thermography.

DWD 81.08(1)(g)3. 3. Plethysmography.

DWD 81.08(1)(g)4. 4. Electronic X-ray analysis of plain radiographs.

DWD 81.08(1)(g)5. 5. Diagnostic ultrasound of the spine.

DWD 81.08(1)(g)6. 6. Somatosensory evoked potentials and motor evoked potentials.

DWD 81.08(1)(h) (h) A health care provider may not order computerized range of motion or strength measuring tests during the period of initial nonsurgical care, but may order these tests during a 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 nonoperative care 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 81.08(1)(i) (i) A health care provider may order personality or psychological 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, a health care provider performing the evaluation shall consider all of the following:

DWD 81.08(1)(i)1. 1. Is symptom magnification occurring?

DWD 81.08(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 81.08(1)(i)3. 3. Are there other personality factors or disorders that are interfering with recovery?

DWD 81.08(1)(i)4. 4. Is the patient chemically dependent?

DWD 81.08(1)(i)5. 5. Are there any interpersonal conflicts interfering with recovery?

DWD 81.08(1)(i)6. 6. Does the patient have a chronic pain syndrome or psychogenic pain?

DWD 81.08(1)(i)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 81.08(1)(j) (j) All of the following are guidelines for diagnostic analgesic blocks or injection studies and include facet joint injection, facet nerve block, epidural differential spinal block, nerve block, and nerve root block:

DWD 81.08(1)(j)1. 1. These procedures are used to localize the source of pain prior to surgery and to diagnose conditions that fail to respond to initial nonoperative care.

DWD 81.08(1)(j)2. 2. These blocks and injections are invasive and when done as diagnostic procedures only are not necessary unless noninvasive procedures have failed to establish the diagnosis.

DWD 81.08(1)(j)3. 3. Selection of patients, choice of procedure, and localization of the level of injection may be determined by documented clinical findings indicating possible pathologic conditions and the source of pain symptoms.

DWD 81.08(1)(j)4. 4. These blocks and injections may also be used as therapeutic modalities and are subject to the guidelines in sub. (5).

DWD 81.08(1)(k) (k) Functional capacity assessment or evaluation is a comprehensive and objective assessment of a patient’s ability to perform work tasks. The components of a functional capacity assessment or evaluation include neuromusculoskeletal screening, tests of manual material handling, assessment of functional mobility, and measurement of postural tolerance. A functional capacity assessment or evaluation is an individualized testing process and the component tests and measurements are determined by the patient’s condition and the requested information. Functional capacity assessments and evaluations are performed to determine and report a patient’s physical capacities in general or to determine work tolerance for a specific job, task, or work activity.

DWD 81.08(1)(k)1. 1. A functional capacity assessment or evaluation is not necessary during the period of initial nonoperative care.

DWD 81.08(1)(k)2. 2. Functional capacity assessment or evaluation is necessary in any of the following circumstances:

DWD 81.08(1)(k)2.a. a. To identify the patient’s permanent activity restrictions and capabilities.

DWD 81.08(1)(k)2.b. b. To assess the patient’s ability to do a specific job.

DWD 81.08(1)(L) (L) Consultations with other health care providers may be initiated at any time by a treating health care provider consistent with standard medical practice.

DWD 81.08(2) (2) General treatment guidelines for thoracic back pain.

DWD 81.08(2)(a) (a) All medical care for thoracic back pain, appropriately assigned to a category of sub. (1) (b) 1. to 3. is determined by the diagnosis and clinical category that the patient has been assigned. General guidelines for treatment modalities are set forth in subs. (3) to (10). Specific treatment guidelines for each clinical category are set forth in subs. (11), (12), and (13) as follows:

DWD 81.08(2)(a)1. 1. Subsection (11) governs regional thoracic back pain.

DWD 81.08(2)(a)2. 2. Subsection (12) governs radicular pain.

DWD 81.08(2)(a)3. 3. Subsection (13) governs myelopathy.

DWD 81.08(2)(b) (b) A health care provider shall, at each visit, reassess the appropriateness of the clinical category assigned and reassign the patient if warranted by new clinical information including symptoms, signs, results of diagnostic testing and opinions, and information obtained from consultations with other health care providers. When the clinical category is changed the treatment plan shall be appropriately modified to reflect the new clinical category. A change of clinical category may not in itself allow a health care provider to continue a therapy or treatment modality past the maximum duration specified in this section or to repeat a therapy or treatment previously provided for the same injury.

DWD 81.08(2)(c) (c) In general, a course of treatment is divided into the following 3 phases:

DWD 81.08(2)(c)1. 1. First, all patients with thoracic back problems, except patients with myelopathy under sub. (1) (b) 3., shall be given initial nonoperative care that may include active and passive treatment modalities, injections, durable medical equipment, and medications. These modalities and guidelines are described in subs. (3), (4), (5), (8), and (10). The period of initial nonsurgical treatment begins with the first clinical passive, active, injection, durable medical equipment, or medication modality initiated. Initial nonsurgical treatment shall result in progressive improvement as specified in sub. (9).

DWD 81.08(2)(c)2. 2. Second, for patients with persistent symptoms, initial nonsurgical management is followed by a period of surgical evaluation. This evaluation shall be completed in a timely manner. Surgery, if necessary, shall be performed as expeditiously as possible consistent with sound medical practice and subs. (6), (11), (12), (13), and s. DWD 81.12 (1). A treating health care provider may do the evaluation or may refer the patient to another health care provider.

DWD 81.08(2)(c)2.a. a. Patients with myelopathy may require immediate surgical therapy.

DWD 81.08(2)(c)2.b. b. Any patient who has had surgery may require postoperative therapy with active and passive treatment modalities. This therapy may be in addition to any received during the period of initial nonsurgical care.

DWD 81.08(2)(c)2.c. c. Surgery shall follow the guidelines in subs. (6), (11), (12), (13), and s. DWD 81.12 (1).

DWD 81.08(2)(c)2.d. d. A decision against surgery at any particular time does not preclude a decision for surgery made at a later date in light of new clinical information.

DWD 81.08(2)(c)3. 3. Third, for those patients who are not candidates for or refuse surgical therapy, or who do not have complete resolution of their symptoms with surgery, a period of chronic management may be necessary. Chronic management modalities are described in s. DWD 81.13 and may also include durable medical equipment as described in sub. (8).

DWD 81.08(2)(d) (d) A treating health care provider may refer the patient for a consultation at any time during the course of treatment consistent with accepted medical practice.