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: DWD 81.12(3)(b)2.a.a. The patient gives a history of rest pain as well as pain with patellofemoral movement, and recurrent effusion, or recurrent dislocation. DWD 81.12(3)(b)2.b.b. There are objective clinical findings of patellar apprehension, synovitis, lateral tracking, or Q angle greater than 15 degrees. DWD 81.12(3)(c)1.1. A health care provider may perform a knee joint replacement for degeneration of articular cartilage or meniscus of knee, ICD-9-CM codes 717.1 to 717.4. DWD 81.12(3)(c)2.2. In addition to the diagnosis in this paragraph, all of the following conditions shall be satisfied for a knee joint replacement: DWD 81.12(3)(c)2.a.a. The patient exhibits limited range of motion, night pain in the joint, or pain with weight-bearing, and no significant relief of pain with an adequate course of initial nonsurgical care. DWD 81.12(3)(c)2.b.b. The patient’s diagnostic findings confirm there is significant loss or erosion of cartilage to the bone, and positive findings of advanced arthritis, and joint destruction with standing films, magnetic resonance imaging scan, or arthroscopy. DWD 81.12(3)(d)1.1. A health care provider may perform an ankle, tarsal, or metatarsal fusion for either of the following diagnoses: DWD 81.12(3)(d)1.a.a. Malunion or nonunion of fracture of ankle, tarsal, or metatarsal, ICD-9-CM code 733.81 or 733.82. DWD 81.12(3)(d)2.2. In addition to one of the diagnoses in this paragraph, the following conditions shall be satisfied for an ankle, tarsal, or metatarsal fusion. For initial nonsurgical care the patient shall have failed to improve with an adequate course of initial nonsurgical care that included any of the following: DWD 81.12(3)(d)2.a.a. Immobilization, which may include casting, bracing, shoe modification, or other orthotics. DWD 81.12(3)(d)3.3. The patient’s clinical findings exhibit both of the following and subd. 4.: DWD 81.12(3)(d)3.a.a. The patient gives a history of pain which is aggravated by activity and weight-bearing, and relieved by xylocaine injection.