DWD 81.01(2)(2) Application. All treatment shall be medically necessary as defined in s. DWD 81.03 (10). In the absence of a specific guideline any applicable general guidelines govern. A departure from a guideline that limits the duration or type of treatment may be appropriate in any of the circumstances specified in s. DWD 81.04 (5). All limitations on the duration of a specific treatment modality or type of modality begin with the first time the modality is initiated after November 1, 2007. This chapter does not apply to treatment of an injury after an insurer has denied liability for the injury, except in cases in which the guidelines apply to treatment initiated after liability has been established.

DWD 81.02DWD 81.02 Incorporation by reference. The ICD-9-CM diagnostic codes referenced in this chapter are contained in the fourth edition of the International Classification of Diseases, Clinical Modification, 9th Revision, 1994, and corresponding annual updates. This document is incorporated by reference.

DWD 81.02 NoteNote: This volume is published by the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services, and may be purchased through the Superintendent of Documents, United States Government Printing Office, Washington, D.C. 20402. It is on file at the Worker’s Compensation Division of the Department of Workforce Development and at the office of the Legislative Reference Bureau.

DWD 81.03(1)(1) “Active treatment” means treatment specified in ss. DWD 81.06 (4), 81.07 (4), 81.08 (4), 81.09 (4), and 81.10 (2) that requires active patient participation in a therapeutic program to increase flexibility, strength, endurance, or awareness of proper body mechanics.

DWD 81.03(2)(2) “Chronic pain” means complaint of persistent pain beyond 12 weeks of appropriate treatment provided under this chapter. It is persistent with verbal and nonverbal pain behaviors that exceed the identifiable pathology and medical condition. It is pain that interferes with physical, psychological, social, or vocational functioning.

DWD 81.03(3)(3) “Condition” means the symptoms, physical signs, clinical findings, and functional status that characterize a person’s complaint, illness, or injury related to a current claim for compensation.

DWD 81.03(4)(4) “Day” means calendar day.

DWD 81.03(5)(5) “Emergency treatment” means treatment that is required for the immediate diagnosis and treatment of a medical condition that, if not immediately diagnosed and treated, could lead to serious physical or mental disability or death, or is immediately necessary to alleviate severe pain. Emergency treatment includes treatment delivered in response to symptoms that may or may not represent an actual emergency but that is necessary to determine whether an emergency exists.

DWD 81.03(6)(6) “Etiology” means the anatomic alteration, physiologic dysfunction, or other biological or psychological abnormality that is considered a cause of the patient’s condition.

DWD 81.03(7)(7) “Functional status” means the ability of an individual to engage in activities of daily living and other social, recreational, and vocational activities.

DWD 81.03(8)(8) “Initial nonsurgical management or treatment” is initial treatment provided after an injury that includes passive treatment, active treatment, injections, and durable medical equipment under ss. DWD 81.06 (3), (4), (5), and (8), 81.07 (3), (4), (5), and (8), 81.08 (3), (4), (5), and (8), 81.09 (3), (4), (5), and (8), and 81.10 (2). Scheduled and nonscheduled medication may be a part of initial nonsurgical treatment. Initial nonsurgical management does not include surgery or chronic management modalities under s. DWD 81.13.

DWD 81.03(9)(9) “Medical imaging procedure” is a technique, process, or technology used to create a visual image of the body or its function. Medical imaging includes X-rays, tomography, angiography, venography, myelography, computed tomography scanning, magnetic resonance imaging scanning, ultrasound imaging, nuclear isotope imaging, positron emission tomography scanning, and thermography.

DWD 81.03(10)(10) “Medically necessary treatment” means those health services for a compensable injury that are reasonable and necessary for the diagnosis and to cure or relieve a condition consistent with any applicable treatment guidelines in this chapter. If ss. DWD 81.04 to 81.13 do not apply, the treatment must be reasonable and necessary for the diagnosis and to cure or relieve a condition consistent with the current accepted standards of practice within the scope of the provider’s license or certification.

DWD 81.03(11)(11) “Neurologic deficit” means a loss of function secondary to involvement of the central or peripheral nervous system. This includes motor loss; spasticity; loss of reflex; radicular or anatomic sensory loss; loss of bowel, bladder or erectile function; impairment of special senses, including vision, hearing, taste, or smell; or deficits in cognitive or memory function.

DWD 81.03(12)(12) “Progressive neurologic deficit” means any neurologic deficit that has become worse by history or been noted by repeated examination since onset.

DWD 81.03(13)(13) “Passive treatment” is any treatment modality specified in ss. DWD 81.06 (3), 81.07 (3), 81.08 (3), 81.09 (3), and 81.10 (2). Passive treatment modalities include bedrest, thermal treatment, traction, acupuncture, electrical muscle stimulation, braces, manual and mechanical therapy, massage, and adjustments.

DWD 81.03(14)(14) “Static neurologic deficit” means any neurologic deficit that has remained the same by history or been noted by repeated examination since onset.

DWD 81.03(15)(15) “Therapeutic injection” is any injection modality specified in ss. DWD 81.06 (5), 81.07 (5), 81.08 (5), 81.09 (5), and 81.10 (2). Therapeutic injections include trigger point injections, sacroiliac injections, facet joint injections, facet nerve blocks, nerve root blocks, epidural injections, soft tissue injections, peripheral nerve blocks, injections for peripheral nerve entrapment, and sympathetic blocks.

DWD 81.03(16)(16) “Week” means calendar week.

DWD 81.04(1)(1) General.

DWD 81.04(1)(a)(a) All treatment shall be medically necessary treatment. A health care provider shall evaluate the medical necessity of all treatment under par. (b) on an ongoing basis. This chapter does not require or permit any more frequent examinations than would normally be required for the condition being treated but may require ongoing evaluation of the patient that is medically necessary and consistent with accepted medical practice.

DWD 81.04(1)(b)(b) The health care provider shall evaluate at each visit whether initial nonsurgical treatment for the low back, cervical, thoracic, and upper extremity conditions specified in ss. DWD 81.06 to 81.09 is effective according to subds. 1. to 3. No later than any applicable treatment response time in ss. DWD 81.06 to 81.09, the health care provider shall evaluate whether the passive, active, injection, or medication treatment modality is resulting in progressive improvement as specified in all of the following:

DWD 81.04(1)(b)1.1. The patient’s subjective complaints of pain or disability are progressively improving, as evidenced by documentation in the medical record of decreased distribution, frequency, or intensity of symptoms.

DWD 81.04(1)(b)2.2. The objective clinical findings are progressively improving, as evidenced by documentation in the medical record of resolution or objectively measured improvement in physical signs of injury.