Chapter DWD 81

DWD 81.09(16)(c) (c) If the patient continues with symptoms and objective physical findings after 12 weeks of initial nonsurgical management 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 traumatic sprains and strains shall be provided under the guidelines of s. DWD 81.13.

DWD 81.09 History History: CR 07-019: cr. Register October 2007 No. 622, eff. 11-1-07.

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

DWD 81.10(1) (1) Scope.

DWD 81.10(1)(a) (a) Complex regional pain syndrome of the upper and lower extremities encompasses any condition of the upper or lower extremity characterized by findings in all of the following categories:

DWD 81.10(1)(a)1. 1. One or more findings reported by the patient in 3 or more of the following categories:

DWD 81.10(1)(a)1.a. a. Positive sensory abnormalities, which include spontaneous pain, mechanical hyperalgesia, thermal hyperalgesia, and deep somatic hyperalgesia.

DWD 81.10(1)(a)1.b. b. Vascular abnormalities, which include vasodilation, vasoconstriction, skin temperature asymmetries, and skin color changes.

DWD 81.10(1)(a)1.c. c. Swelling or sweating abnormalities.

DWD 81.10(1)(a)1.d. d. Motor and trophic changes, which include motor weakness, tremor, abnormal movements, coordination deficits, nail changes, hair changes, skin atrophy, joint stiffness, and soft tissue changes.

DWD 81.10(1)(a)2. 2. One or more findings observed by the health care provider in 2 or more of the following categories:

DWD 81.10(1)(a)2.a. a. Positive sensory abnormalities, which include spontaneous pain, mechanical hyperalgesia, thermal hyperalgesia, and deep somatic hyperalgesia.

DWD 81.10(1)(a)2.b. b. Vascular abnormalities, which include vasodilation, vasoconstriction, skin temperature asymmetries, and skin color changes.

DWD 81.10(1)(a)2.c. c. Edema or sweating abnormalities, which include swelling, hyperhidrosis, and hypohidrosis.

DWD 81.10(1)(a)2.d. d. Motor and trophic changes, which include motor weakness, tremor, abnormal movements, coordination deficits, nail changes, hair changes, skin atrophy, joint stiffness, and soft tissue changes.

DWD 81.10(1)(b) (b) Complex regional pain syndrome of the upper and lower extremities includes the diagnoses of complex regional pain syndrome, reflex sympathetic dystrophy, causalgia, Sudek’s atrophy, algoneurodystrophy, shoulder-hand syndrome, including ICD-9-CM codes 337.9, 354.4, and 733.7.

DWD 81.10(1)(c) (c) Complex regional pain syndrome occurs as a complication of another preceding injury. The treatment guidelines of this section refer to the treatment of the body part affected by the complex regional pain syndrome. The treatment for any condition not affected by complex regional pain syndrome continues to be subject to whatever treatment guidelines otherwise apply. Any treatment under this section for complex regional pain syndrome may be in addition to treatment received for the original condition.

DWD 81.10(1)(d) (d) Thermography may be used in the diagnosis of complex regional pain syndrome and is considered an adjunct to physical examination.

DWD 81.10(1)(e) (e) For a patient with continued clinical signs and symptoms of complex regional pain syndrome, further diagnostic testing may be appropriate.

DWD 81.10(2) (2) Initial nonsurgical involvement.

DWD 81.10(2)(a) (a) A health care provider shall use initial nonsurgical management for all patients with complex regional pain syndrome and this shall be the first phase of treatment. Any course or program of initial nonsurgical management is limited to the modalities specified in pars. (b) to (i).

DWD 81.10(2)(b) (b) The only therapeutic injection modalities necessary for complex regional pain syndrome are sympathetic block, intravenous infusion of steroids or sympatholytics, or epidural block.

DWD 81.10(2)(b)1. 1. Unless medically contraindicated, sympathetic blocks or the intravenous infusion of steroids or sympatholytics shall be used if complex regional pain syndrome has continued for 4 weeks and the patient remains disabled as a result of the complex regional pain syndrome. All of the following guidelines apply to therapeutic injection modalities:

DWD 81.10(2)(b)1.a. a. Time for treatment response is within 30 minutes.

DWD 81.10(2)(b)1.b. b. Maximum treatment frequency permits a repeat injection at a site if there was a positive response to the first injection. If subsequent injections demonstrate diminishing control of symptoms or fail to facilitate objective functional gains, then injections shall be discontinued. Only 3 injections to different sites per patient visit.

DWD 81.10(2)(b)1.c. c. Maximum treatment duration may be continued as long as injections control symptoms and facilitate objective functional gains if the period of improvement is progressively longer with each injection.

DWD 81.10(2)(b)2. 2. Epidural block may only be performed in patients who had an incomplete improvement with sympathetic block or intravenous infusion of steroids or sympatholytics.

DWD 81.10(2)(c) (c) Only the passive treatment modalities set forth in pars. (d) to (g) are necessary. These passive treatment modalities in a clinical setting or requiring attendance by a health care provider are not necessary beyond 12 weeks from the first modality initiated for treatment of complex regional pain syndrome.

DWD 81.10(2)(d) (d) For purposes of this paragraph, “thermal treatment” includes all superficial and deep heating and cooling modalities. Superficial thermal modalities include hot packs, hot soaks, hot water bottles, hydrocollators, heating pads, ice packs, cold soaks, infrared, whirlpool, and fluidotherapy. Deep thermal modalities include diathermy, ultrasound, and microwave. All of the following guidelines apply to thermal treatment:

DWD 81.10(2)(d)1. 1. Treatment given in a clinical setting:

DWD 81.10(2)(d)1.a. a. Time for treatment response is 2 to 4 treatments.

DWD 81.10(2)(d)1.b. b. Maximum treatment frequency is up to 5 times per week for the first one to 3 weeks, decreasing in frequency until the end of the maximum treatment duration period in subd. 1. c.

DWD 81.10(2)(d)1.c. c. Maximum treatment duration is 12 weeks of treatment in a clinical setting but only if given in conjunction with other therapies specified in this subsection.

DWD 81.10(2)(d)2. 2. Home use of thermal modalities may be prescribed at any time during the course of treatment. Home use may only involve hot packs, hot soaks, hot water bottles, hydrocollators, heating pads, ice packs, and cold soaks that can be applied by the patient without professional assistance. Home use of thermal modalities may not require any special training or monitoring, other than that usually provided by a health care provider during an office visit.

DWD 81.10(2)(e) (e) For purposes of this paragraph, “desensitizing procedures” includes stroking or friction massage, stress loading, and contrast baths. All of the following guidelines apply to desensitizing procedures:

DWD 81.10(2)(e)1. 1. Time for treatment response is 3 to 5 treatments.

DWD 81.10(2)(e)2. 2. Maximum treatment frequency in a clinical setting is up to 5 times per week for the first one to 2 weeks decreasing in frequency until the end of the maximum treatment duration period in subd. 3.

DWD 81.10(2)(e)3. 3. Maximum treatment duration in a clinical setting is 12 weeks. Home use of desensitizing procedures may be prescribed at any time during the course of treatment.

DWD 81.10(2)(f) (f) For purposes of this paragraph, “electrical stimulation” includes galvanic stimulation, transcutaneous electrical nerve stimulation, interferential, and microcurrent techniques. All of the following guidelines apply to electrical stimulation treatment:

DWD 81.10(2)(f)1. 1. Treatment given in a clinical setting:

DWD 81.10(2)(f)1.a. a. Time for treatment response is 2 to 4 treatments.

DWD 81.10(2)(f)1.b. b. Maximum treatment frequency is up to 5 times per week for the first one to 3 weeks, decreasing in frequency until the end of the maximum treatment duration period in subd. 1. c.

DWD 81.10(2)(f)1.c. c. Maximum treatment duration is 12 weeks of treatment in a clinical setting, but only if given in conjunction with other therapies.

DWD 81.10(2)(f)2. 2. Home use of an electrical stimulation device may be prescribed at any time during a course of treatment. Initial use of an electrical stimulation device shall be in a supervised setting in order to ensure proper electrode placement and patient education. All of the following guidelines apply to home use of an electrical stimulation device:

DWD 81.10(2)(f)2.a. a. Time for patient education and training is one to 3 sessions.

DWD 81.10(2)(f)2.b. b. Patient may use the electrical stimulation device unsupervised for one month, at which time effectiveness of the treatment shall be reevaluated by a health care provider before continuing home use of the device.

DWD 81.10(2)(g) (g) For purposes of this paragraph, “acupuncture treatments” include endorphin-mediated analgesic therapy that includes classic acupuncture and acupressure. All of the following guidelines apply to acupuncture treatments:

DWD 81.10(2)(g)1. 1. Time for treatment response is 3 to 5 sessions.

DWD 81.10(2)(g)2. 2. Maximum treatment frequency is up to 3 times per week for the first one to 3 weeks, decreasing in frequency until the end of the maximum treatment duration period in subd. 3.

DWD 81.10(2)(g)3. 3. Maximum treatment duration is 12 weeks.

DWD 81.10(2)(h) (h) Active treatment includes supervised and unsupervised exercise. After the first week of treatment, initial nonsurgical management shall include exercise. Exercise is essential for a return to normal activity and shall include active patient participation in activities designed to increase flexibility, strength, endurance, or muscle relaxation. Exercise shall be specifically aimed at the involved musculature. Exercises shall be evaluated to determine if the desired goals are being attained. Strength, flexibility, or endurance shall be objectively measured. A health care provider may objectively measure the treatment response as often as necessary for optimal care.

DWD 81.10(2)(h)1. 1. ‘Guidelines for supervised exercise.’ One goal of a supervised exercise program shall be to teach the patient how to maintain and maximize any gains experienced from exercise. Self-management of the condition shall be promoted. All of the following guidelines apply to supervised exercise:

DWD 81.10(2)(h)1.a. a. Maximum treatment frequency is up to 5 times per week for 3 weeks and shall decrease in frequency until the end of the maximum treatment duration period in subd. 1. b.

DWD 81.10(2)(h)1.b. b. Maximum duration is 12 weeks.

DWD 81.10(2)(h)2. 2. ‘Guidelines for unsupervised exercise.’ Unsupervised exercise shall be provided in the least intensive setting and may supplement or follow the period of supervised exercise. Maximum duration is unlimited.

DWD 81.10(2)(i) (i) Oral medications may be necessary in accordance with accepted medical practice.

DWD 81.10(3) (3) Surgery.

DWD 81.10(3)(a) (a) Surgical sympathectomy may only be performed on a patient who had a sustained but incomplete improvement with sympathetic blocks by injection.

DWD 81.10(3)(b) (b) There shall be appropriate psychological assessment prior to implantation of a spinal cord stimulator or intrathecal drug delivery system to determine whether the patient is a suitable candidate for this type of treatment.

DWD 81.10(4) (4) Chronic management. If the patient continues with symptoms and objective physical findings after surgery, 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. Any course or program of chronic management for patients with complex regional pain syndrome shall be provided under the guidelines of s. DWD 81.13.

DWD 81.10 History History: CR 07-019: cr. Register October 2007 No. 622, eff. 11-1-07.

DWD 81.11 DWD 81.11 Inpatient hospitalization guidelines.

DWD 81.11(1) (1) General principles.

DWD 81.11(1)(a) (a) For purposes of this chapter, hospitalization is characterized as inpatient if the patient spends at least one night in a hospital, except for a patient in outpatient short stay status recovering after surgery for less than 24 hours or a patient in observation status.

DWD 81.11(1)(b) (b) Unless a patient’s condition requires special care, only ward or semiprivate accommodations are necessary. The admitting health care provider shall document the patient’s special care needs.

DWD 81.11(1)(c) (c) Admission before the day of surgery is necessary only if it is medically necessary to stabilize the patient before surgery. Admission before the day of surgery to perform any part of a preoperative work-up that could have been completed as an outpatient is not necessary.

DWD 81.11(1)(d) (d) Inpatient hospitalization solely for physical therapy, bedrest, or administration of injectable drugs is necessary only if the treatment is otherwise necessary and the patient’s condition makes the patient unable to perform the activities of daily life and participate in the patient’s own treatment and self-care.

DWD 81.11(1)(e) (e) Discharge from the hospital shall be at the earliest possible date consistent with proper health care.

DWD 81.11(2) (2) Specific guidelines for hospital admission of patients with low back pain.

DWD 81.11(2)(a) (a) A health care provider shall direct hospitalization for low back pain in the circumstances in pars. (b) to (e).

DWD 81.11(2)(b) (b) When the patient experiences incapacitating pain as evidenced by inability to mobilize for activities of daily living, for example unable to ambulate to the bathroom, and, in addition, the intensity of service during admission meets any of the following:

DWD 81.11(2)(b)1. 1. Physical therapy is necessary at least twice daily for assistance with mobility. Heat, cold, ultrasound, and massage therapy alone do not meet this criterion.

DWD 81.11(2)(b)2. 2. Muscle relaxants or narcotic analgesics are necessary intramuscularly or intravenously for a minimum of 3 injections in 24 hours. Need for parenteral analgesics is determined by any of the following:

DWD 81.11(2)(b)2.a. a. An inability to take oral medications or diet by mouth.

DWD 81.11(2)(b)2.b. b. An inability to achieve relief with aggressive oral analgesics.

DWD 81.11(2)(c) (c) For surgery that is otherwise necessary according to s. DWD 81.12 (1) and is appropriately scheduled as an inpatient procedure.

DWD 81.11(2)(d) (d) For evaluation and treatment of cauda equina syndrome according to s. DWD 81.06 (13).

DWD 81.11(2)(e) (e) For evaluation and treatment of foot drop or progressive neurologic deficit according to s. DWD 81.06 (13).

DWD 81.11 History History: CR 07-019: cr. Register October 2007 No. 622, eff. 11-1-07.

DWD 81.12 DWD 81.12 Guidelines for surgical procedures.

DWD 81.12(1) (1) Spinal surgery.

DWD 81.12(1)(a) (a) General. In addition to this section, initial nonsurgical, surgical and chronic management guidelines are also in s. DWD 81.06, relating to low back pain; s. DWD 81.07, relating to neck pain; and s. DWD 81.08, relating to thoracic back pain.

DWD 81.12(1)(b) (b) Surgical decompression of lumbar nerve root or roots. Surgical decompression of a lumbar nerve root or roots includes all of the following lumbar procedures: laminectomy, laminotomy, discectomy, microdiscectomy, percutaneous discectomy, or foraminotomy. The procedure at each nerve root is subject independently to the requirements of subds. 1. and 2.

DWD 81.12(1)(b)1. 1. A health care provider may perform surgical decompression of a lumbar nerve root for any of the following diagnoses:

DWD 81.12(1)(b)1.a. a. Intractable and incapacitating regional low back pain with positive nerve root tension signs and an imaging study showing displacement of lumbar intervertebral disc that impinges significantly on a nerve root or the thecal sac, ICD-9-CM code 722.10.

DWD 81.12(1)(b)1.b. b. Sciatica, ICD-9-CM code 724.3.

DWD 81.12(1)(b)1.c. c. Lumbosacral radiculopathy or radiculitis, ICD-9-CM code 724.4.

DWD 81.12(1)(b)2. 2. Any of the following conditions in this subdivision and any of the conditions in subd. 3. shall be satisfied to indicate that the surgery is reasonably required. For the response to nonsurgical care, the patient’s condition includes one of the following:

DWD 81.12(1)(b)2.a. a. Failure to improve with a minimum of 8 weeks of initial nonsurgical care.