DWD 81.12(1)(b)2.c. c. Progressive neurological deficits.

DWD 81.12(1)(b)3. 3. The patient exhibits one of the clinical findings of subd. 3. a. in combination with the test results of subd. 3. b. or, in the case of diagnosis in subd. 1. a., a decompression of the lumbar nerve root is the appropriate treatment for the patient’s condition.

DWD 81.12(1)(b)3.a. a. Subjective sensory symptoms in a dermatomal distribution that may include radiating pain, burning, numbness, tingling, or paresthesia, or objective clinical findings of nerve root specific motor deficit, including foot drop or quadriceps weakness, reflex changes, or positive electromyography.

DWD 81.12(1)(b)3.b. b. Medical imaging test results that correlate with the level of nerve root involvement consistent with both the subjective and objective findings.

DWD 81.12(1)(c) (c) Surgical decompression of a cervical nerve root. Surgical decompression of a cervical nerve root or roots includes all of the following cervical procedures: laminectomy, laminotomy, discectomy, foraminotomy with, or without, fusion. For decompression of multiple nerve roots, the procedure at each nerve root is subject to the guidelines of subds. 1. and 2.

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

DWD 81.12(1)(c)1.a. a. Displacement of cervical intervertebral disc, ICD-9-CM code 722.0, excluding fracture.

DWD 81.12(1)(c)1.b. b. Cervical radiculopathy or radiculitis, ICD-9-CM code 723.4, excluding fracture.

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

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

DWD 81.12(1)(c)2.b. b. Cervical compressive myelopathy.

DWD 81.12(1)(c)2.c. c. Progressive neurologic deficits.

DWD 81.12(1)(c)3. 3. The patient exhibits one of the clinical findings of subd. 3. a. in combination with the test results of subd. 3. b.

DWD 81.12(1)(c)3.a. a. Subjective sensory symptoms in a dermatomal distribution that may include radiating pain, burning, numbness, tingling or paresthesia, or objective clinical findings of nerve root specific motor deficit, reflex changes, or positive electromyography.

DWD 81.12(1)(c)3.b. b. Medical imaging test results that correlate with the level of nerve root involvement consistent with both the subjective and objective findings.

DWD 81.12(1)(d) (d) Lumbar arthrodesis with or without instrumentation. A health care provider may perform surgery for a lumbar arthrodesis when any of the following diagnoses are present to indicate that the surgery is reasonably required:

DWD 81.12(1)(d)1. 1. Unstable lumbar vertebral fracture, ICD-9-CM codes 805.4, 805.5, 806.4, and 806.5.

DWD 81.12(1)(d)2. 2. For a second or third surgery only, documented reextrusion or redisplacement of lumbar intervertebral disc, ICD-9-CM code 722.10, after previous successful disc surgery at the same level and new lumbar radiculopathy with or without incapacitating back pain, ICD-9-CM code 724.4. Documentation under this subdivision shall include a magnetic resonance imaging scan or computed tomography scan or a myelogram.

DWD 81.12(1)(d)3. 3. Traumatic spinal deformity including a history of compression or wedge fracture or fractures, ICD-9-CM code 733.1, and demonstrated acquired kyphosis or scoliosis, ICD-9-CM codes 737.1, 737.10, 737.30, 737.41, and 737.43.

DWD 81.12(1)(d)4. 4. Incapacitating low back pain, ICD-9-CM code 724.2, for longer than 3 months, and any of the following conditions involving lumbar segments L-3 and below is present:

DWD 81.12(1)(d)4.a. a. For the first surgery only, degenerative disc disease, ICD-9-CM code 722.4, 722.5, 722.6, or 722.7, with postoperative documentation of instability created or found at the time of surgery, or positive discogram at one or 2 levels.

DWD 81.12(1)(d)4.b. b. Pseudoarthrosis, ICD-9-CM code 733.82.

DWD 81.12(1)(d)4.c. c. For the second or third surgery only, previously operated disc.

DWD 81.12(1)(d)4.d. d. Spondylolisthesis.

DWD 81.12(1)(d)5. 5. A health care provider may not perform a lumbar arthrodesis as the first primary surgical procedure for a new, acute lumbosacral disc herniation with unilateral radiating leg pain in a radicular pattern with or without neurological deficit.

DWD 81.12(2) (2) Upper extremity surgery.

DWD 81.12(2)(a) (a) General. Initial nonsurgical, surgical, and chronic management guidelines for upper extremity disorders are set forth in s. DWD 81.09 (1) to (16).

DWD 81.12(2)(b) (b) Rotator cuff repair. A health care provider may perform rotator cuff surgery for any of the following diagnoses:

DWD 81.12(2)(b)1. 1. Rotator cuff syndrome of the shoulder, ICD-9-CM code 726.1, and allied disorders, including unspecified disorders of shoulder bursae and tendons, ICD-9-CM code 726.10; calcifying tendinitis of shoulder, ICD-9-CM code 726.11; bicipital tenosynovitis, ICD-9-CM code 726.12; and other specified disorders, ICD-9-CM code 726.19.