DWD 81.12(2)(c)(c) Criteria and indications for rotator cuff repair. In addition to one of the diagnoses in par. (b), both of the following conditions shall be satisfied to indicate that surgery for rotator cuff repair is necessary: DWD 81.12(2)(c)1.1. The patient’s condition failed to improve in response to nonsurgical care with adequate initial nonsurgical treatment. DWD 81.12(2)(c)2.b.b. Weak or absent abduction and tenderness over rotator cuff or pain relief obtained with an injection of anesthetic for diagnostic or therapeutic trial. DWD 81.12(2)(c)2.c.c. Positive findings in arthrogram, magnetic resonance imaging scan, or ultrasound, or positive findings on previous arthroscopy, if performed. DWD 81.12(2)(d)(d) Acromioplasty diagnosis. A health care provider may perform acromioplasty for the diagnosis of acromial impingement syndrome, ICD-9-CM codes 726.0 to 726.2. In addition to the diagnosis in this paragraph, both of the following conditions shall be satisfied to indicate that surgery is necessary: DWD 81.12(2)(d)1.1. The patient’s condition has failed to improve in response to nonsurgical care after adequate initial nonsurgical care. DWD 81.12(2)(d)2.2. The patient’s clinical findings exhibit pain with active elevation from 90 to 130 degrees, pain at night, and a positive impingement test. DWD 81.12(2)(e)(e) Repair of acromioclavicular or costoclavicular ligaments. A health care provider may perform surgical repair of acromioclavicular or costoclavicular ligaments for the diagnosis of acromioclavicular separation, ICD-9-CM codes 831.04 to 831.14. DWD 81.12(2)(e)1.1. In addition to the diagnosis in this paragraph, the guidelines in subds. 2. and 3. shall be satisfied for repair of acromioclavicular or costoclavicular ligaments. DWD 81.12(2)(e)2.2. The patient’s condition or response to nonsurgical care includes any of the following: DWD 81.12(2)(e)2.a.a. Failure to improve after at least a one-week trial period in a support brace. DWD 81.12(2)(e)3.3. The patient’s clinical findings exhibit localized pain at the acromioclavicular joint and prominent distal clavicle and radiographic evidence of separation at the acromioclavicular joint. DWD 81.12(2)(f)(f) Excision of distal clavicle diagnosis. A health care provider may perform excision of the distal clavicle for any of the following diagnoses specified in subd. 1. to 3.: DWD 81.12(2)(f)2.2. Osteoarthrosis of the acromioclavicular joint, ICD-9-CM codes 715.11, 715.21, and 715.31. DWD 81.12(2)(g)(g) Criteria and indications for excision of distal clavicle. In addition to one of the diagnosis in par. (f), all of the following conditions shall be satisfied for excision of distal clavicle: DWD 81.12(2)(g)1.1. The patient’s condition failed to improve in response to nonsurgical care with adequate initial nonsurgical care. DWD 81.12(2)(g)2.a.a. Pain at the acromioclavicular joint, with aggravation of pain with motion of shoulder or carrying weight. DWD 81.12(2)(g)2.b.b. Confirmation that separation of the acromioclavicular joint is unresolved and prominent distal clavicle, or pain relief obtained with an injection of anesthetic for diagnostic or therapeutic trial. DWD 81.12(2)(g)2.c.c. Separation at the acromioclavicular joint with weight-bearing films or severe degenerative joint disease at the acromioclavicular joint noted on X-rays. DWD 81.12(2)(h)(h) Repair of shoulder dislocation or subluxation, any procedure. DWD 81.12(2)(h)1.1. A health care provider may perform surgical repair of a shoulder dislocation for any of the following diagnoses: