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: DWD 81.12(3)(a)2.2. In addition to one of the diagnoses in this paragraph, all of the conditions in subd. 2. a. to c. shall be satisfied for anterior cruciate ligament reconstruction. Pain alone is not an indication. DWD 81.12(3)(a)2.a.a. The patient gives a history of instability of the knee described as “buckling or giving way” with significant effusion at time of injury, or description of injury indicates a rotary twisting or hyperextension occurred. DWD 81.12(3)(a)2.b.b. There are objective clinical findings of positive Lachman’s sign, positive pivot shift, or positive anterior drawer. DWD 81.12(3)(a)2.c.c. There are positive diagnostic findings with arthrogram, magnetic resonance imaging scan, or arthroscopy, and there is no evidence of severe compartmental arthritis. DWD 81.12(3)(b)1.1. A health care provider may perform patellar tendon realignment for the diagnosis of dislocation of patellar, open, ICD-9-CM code 836.3; or closed, ICD-9-CM code 836.4; or chronic residuals of dislocation. DWD 81.12(3)(b)2.2. In addition to the diagnosis in this paragraph, all of the following conditions shall be satisfied for a patellar tendon realignment: