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: DWD 81.12(2)(h)2.2. In addition to one of the diagnoses in this paragraph, all of the following clinical findings shall exist for repair of a shoulder dislocation: DWD 81.12(2)(h)2.a.a. The patient exhibits a history of multiple dislocations or subluxations that inhibit activities of daily living. DWD 81.12(2)(h)2.b.b. X-ray findings are consistent with multiple dislocations or subluxations. DWD 81.12(2)(i)1.1. A health care provider may perform surgical repair of a proximal biceps tendon for the diagnosis of proximal rupture of the biceps, ICD-9-CM code 727.62 or 840.8. DWD 81.12(2)(i)2.2. In addition to the diagnosis in subd. 1., both of the following conditions shall be satisfied for repair of proximal biceps tendon: DWD 81.12(2)(i)2.a.a. The procedure may be done alone or in conjunction with another necessary repair of the rotator cuff. DWD 81.12(2)(i)2.b.b. The patient’s clinical findings exhibit pain that does not resolve with attempt to use arm and palpation of “bulge” in upper aspect of arm. DWD 81.12(2)(m)(m) Muscle pain syndromes. Surgery is not necessary for muscle pain syndromes. DWD 81.12(2)(n)(n) Traumatic sprains and strains. Surgery is not necessary for the treatment of traumatic sprains and strains, unless there is clinical evidence of complete tissue disruption. Patients with complete tissue disruption may need immediate surgery. DWD 81.12(3)(a)1.1. A health care provider may perform surgical repair of the anterior cruciate ligament, including arthroscopic repair, for any of the following diagnoses: