DWD 81.06(9)(d)(d) The patient’s functional status, especially vocational activity, is progressively improving, as evidenced by documentation in the medical record or documentation of work ability involving less restrictive limitations on activity.

DWD 81.06(9)(e)(e) If there is not progressive improvement in at least 2 criteria specified in pars. (b) to (d), the modality shall be discontinued or significantly modified or a health care provider shall reconsider the diagnosis. The evaluation of the effectiveness of the treatment modality may be delegated to another health care provider.

DWD 81.06(10)(a)(a) Prescription of controlled substance medications under ch. 450, Stats., including opioids and narcotics, are indicated primarily for the treatment of severe acute pain. These medications are not recommended in the treatment of patients with persistent low back pain.

DWD 81.06(10)(b)(b) Patients with radicular pain may require longer periods of treatment.

DWD 81.06(10)(c)(c) A health care provider shall document the rationale for the use of any scheduled medication. Treatment with nonnarcotic medication may be appropriate during any phase of treatment and intermittently after all other treatment has been discontinued. The prescribing health care provider shall determine that ongoing medication is effective treatment for the patient’s condition.

DWD 81.06(11)(a)(a) A health care provider shall use initial nonsurgical treatment as the first phase of treatment for all patients with regional low back pain under sub. (1) (b) 1.

DWD 81.06(11)(a)1.1. The passive, active, injection, durable medical equipment, and medication treatment modalities and procedures in subs. (3), (4), (5), (8), and (10) may be used in sequence or simultaneously during the period of initial nonsurgical management, depending on the severity of the condition.

DWD 81.06(11)(a)2.2. The only therapeutic injections necessary for patients with regional low back pain are trigger point injections, facet joint injections, facet nerve injections, sacroiliac joint injections, and epidural blocks, and their use shall meet the guidelines of sub. (5).

DWD 81.06(11)(a)3.3. After the first week of treatment, initial nonsurgical treatment shall at all times contain active treatment modalities according to the guidelines in sub. (4).

DWD 81.06(11)(a)5.5. Except as otherwise specified in sub. (3), passive treatment modalities in a clinic setting or requiring attendance by a health care provider are not necessary beyond 12 weeks after any passive modality other than bedrest or bracing is first initiated.

DWD 81.06(11)(b)(b) Surgical evaluation or chronic management is necessary if the patient continues with symptoms and physical findings after the course of initial nonsurgical care and if the patient’s condition prevents the resumption of the regular activities of daily life, including regular vocational activities. The purpose of surgical evaluation is to determine whether surgery is necessary in the treatment of a patient who has failed to recover with initial nonsurgical care. If the patient is not a surgical candidate, then chronic management is necessary.

DWD 81.06(11)(b)1.1. Surgical evaluation, if necessary, may begin as soon as 8 weeks after, but shall begin no later than 12 weeks after, beginning initial nonsurgical management. An initial recommendation or decision against surgery may not preclude surgery at a later date.

DWD 81.06(11)(b)2.2. Surgical evaluation may include the use of appropriate medical imaging techniques. The imaging technique shall be chosen on the basis of the suspected etiology of the patient’s condition but a health care provider shall follow the guidelines in s. DWD 81.05. Medical imaging studies that do not meet these guidelines are not necessary.

DWD 81.06(11)(b)3.3. Surgical evaluation may also include diagnostic blocks and injections. These blocks and injections are only necessary if their use is consistent with the guidelines of sub. (1) (j).

DWD 81.06(11)(b)5.5. Consultation with other health care providers may be appropriate as part of the surgical evaluation. The need for consultation and the choice of consultant will be determined by the findings on medical imaging, diagnostic analgesic blocks, and injections, if performed, and the patient’s ongoing subjective complaints and physical findings.

DWD 81.06(11)(b)6.6. The only surgical procedures necessary for patients with regional low back pain are decompression of a lumbar nerve root or lumbar arthrodesis, with or without instrumentation, which shall meet the guidelines of sub. (6) and s. DWD 81.12 (1). For patients with failed back surgery, spinal cord stimulators or intrathecal drug delivery systems may be necessary and consistent with sub. (6) (d).

DWD 81.06(11)(b)6.a.a. If surgery is necessary, it shall be offered to the patient as soon as possible. If the patient agrees to the proposed surgery, it shall be performed as expeditiously as possible consistent with sound medical practice.

DWD 81.06(11)(b)6.b.b. If surgery is not necessary, or if the patient does not wish to proceed with surgery, then the patient is a candidate for chronic management under the guidelines in s. DWD 81.13.

DWD 81.06(11)(c)(c) If the patient continues with symptoms and objective physical findings after surgical therapy has been rendered or the patient refuses surgical therapy or the patient was not a candidate for surgical therapy, and if the patient’s condition prevents the resumption of the regular activities of daily life including regular vocational activities, then the patient may be a candidate for chronic management that shall be provided under the guidelines in s. DWD 81.13.

DWD 81.06(12)(a)(a) Initial nonsurgical treatment is appropriate for all patients with radicular pain, with or without regional low back pain, with no or static neurologic deficits under sub. (1) (b) 2., and shall be the first phase of treatment. It shall be provided within the guidelines of sub. (11) (a), with the following modifications: Epidural blocks and nerve root and peripheral nerve blocks are the only therapeutic injections necessary for patients with radicular pain only. If there is a component of regional low back pain, therapeutic facet joint injections, facet nerve injections, trigger point injections, and sacroiliac injections may also be necessary.

DWD 81.06(12)(b)(b) Surgical evaluation or chronic management is necessary if the patient continues with symptoms and physical findings after the course of initial nonsurgical care and if the patient’s condition prevents the resumption of the regular activities of daily life, including regular vocational activities. It shall be provided within the guidelines of sub. (11) (b).

DWD 81.06(12)(c)(c) If the patient continues with symptoms and objective physical findings after surgical therapy has been rendered or the patient refused surgical therapy or the patient was not a candidate for surgical therapy, and if the patient’s condition prevents the resumption of the regular activities of daily life including regular vocational activities, then the patient may be a candidate for chronic management. Any course or program of chronic management for patients with radicular pain, with or without regional low back pain, with static neurologic deficits shall be provided under the guidelines of s. DWD 81.13.

DWD 81.06(13)(13) Specific treatment guidelines for cauda equina syndrome and for radicular pain, with or without regional low back pain, with progressive neurologic deficits.

DWD 81.06(13)(a)(a) Patients with cauda equina syndrome or with radicular pain, with or without regional low back pain, with progressive neurologic deficits may require immediate or emergency surgical evaluation at any time during the course of the overall treatment. The decision to proceed with surgical evaluation is made by a health care provider based on the type of neurologic changes observed, the severity of the changes, the rate of progression of the changes, and the response to any initial nonsurgical treatments. Surgery, if necessary, may be performed at any time during the course of treatment. Surgical evaluation and surgery shall be provided within the guidelines of sub. (11) (b), except that surgical evaluation and surgical therapy may begin at any time.