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(3) Surgery.
(a) Surgical sympathectomy may only be performed on a patient who had a sustained but incomplete improvement with sympathetic blocks by injection.
(b) There shall be appropriate psychological assessment prior to implantation of a spinal cord stimulator or intrathecal drug delivery system to determine whether the patient is a suitable candidate for this type of treatment.
(4) Chronic management. If the patient continues with symptoms and objective physical findings after surgery, or the patient refuses surgery, or the patient was not a candidate for surgery, 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 complex regional pain syndrome shall be provided under the guidelines of s. DWD 81.13.
History: CR 07-019: cr. Register October 2007 No. 622, eff. 11-1-07.
DWD 81.11 Inpatient hospitalization guidelines.
(1) General principles.
(a) For purposes of this chapter, hospitalization is characterized as inpatient if the patient spends at least one night in a hospital, except for a patient in outpatient short stay status recovering after surgery for less than 24 hours or a patient in observation status.
(b) Unless a patient’s condition requires special care, only ward or semiprivate accommodations are necessary. The admitting health care provider shall document the patient’s special care needs.
(c) Admission before the day of surgery is necessary only if it is medically necessary to stabilize the patient before surgery. Admission before the day of surgery to perform any part of a preoperative work-up that could have been completed as an outpatient is not necessary.
(d) Inpatient hospitalization solely for physical therapy, bedrest, or administration of injectable drugs is necessary only if the treatment is otherwise necessary and the patient’s condition makes the patient unable to perform the activities of daily life and participate in the patient’s own treatment and self-care.
(e) Discharge from the hospital shall be at the earliest possible date consistent with proper health care.
(2) Specific guidelines for hospital admission of patients with low back pain.
(a) A health care provider shall direct hospitalization for low back pain in the circumstances in pars. (b) to (e).
(b) When the patient experiences incapacitating pain as evidenced by inability to mobilize for activities of daily living, for example unable to ambulate to the bathroom, and, in addition, the intensity of service during admission meets any of the following:
1. Physical therapy is necessary at least twice daily for assistance with mobility. Heat, cold, ultrasound, and massage therapy alone do not meet this criterion.
2. Muscle relaxants or narcotic analgesics are necessary intramuscularly or intravenously for a minimum of 3 injections in 24 hours. Need for parenteral analgesics is determined by any of the following:
a. An inability to take oral medications or diet by mouth.
b. An inability to achieve relief with aggressive oral analgesics.
(c) For surgery that is otherwise necessary according to s. DWD 81.12 (1) and is appropriately scheduled as an inpatient procedure.
(d) For evaluation and treatment of cauda equina syndrome according to s. DWD 81.06 (13).
(e) For evaluation and treatment of foot drop or progressive neurologic deficit according to s. DWD 81.06 (13).
History: CR 07-019: cr. Register October 2007 No. 622, eff. 11-1-07.
DWD 81.12 Guidelines for surgical procedures.
(1) Spinal surgery.
(a) General. In addition to this section, initial nonsurgical, surgical and chronic management guidelines are also in s. DWD 81.06, relating to low back pain; s. DWD 81.07, relating to neck pain; and s. DWD 81.08, relating to thoracic back pain.
(b) Surgical decompression of lumbar nerve root or roots. Surgical decompression of a lumbar nerve root or roots includes all of the following lumbar procedures: laminectomy, laminotomy, discectomy, microdiscectomy, percutaneous discectomy, or foraminotomy. The procedure at each nerve root is subject independently to the requirements of subds. 1. and 2.
1. A health care provider may perform surgical decompression of a lumbar nerve root for any of the following diagnoses:
a. Intractable and incapacitating regional low back pain with positive nerve root tension signs and an imaging study showing displacement of lumbar intervertebral disc that impinges significantly on a nerve root or the thecal sac, ICD-9-CM code 722.10.
b. Sciatica, ICD-9-CM code 724.3.
c. Lumbosacral radiculopathy or radiculitis, ICD-9-CM code 724.4.
2. Any of the following conditions in this subdivision and any of the conditions in subd. 3. shall be satisfied to indicate that the surgery is reasonably required. For the response to nonsurgical care, the patient’s condition includes one of the following:
a. Failure to improve with a minimum of 8 weeks of initial nonsurgical care.
b. Cauda equina syndrome, ICD-9-CM code 344.6, 344.60, or 344.61.
c. Progressive neurological deficits.
3. The patient exhibits one of the clinical findings of subd. 3. a. in combination with the test results of subd. 3. b. or, in the case of diagnosis in subd. 1. a., a decompression of the lumbar nerve root is the appropriate treatment for the patient’s condition.
a. Subjective sensory symptoms in a dermatomal distribution that may include radiating pain, burning, numbness, tingling, or paresthesia, or objective clinical findings of nerve root specific motor deficit, including foot drop or quadriceps weakness, reflex changes, or positive electromyography.
b. Medical imaging test results that correlate with the level of nerve root involvement consistent with both the subjective and objective findings.
(c) Surgical decompression of a cervical nerve root. Surgical decompression of a cervical nerve root or roots includes all of the following cervical procedures: laminectomy, laminotomy, discectomy, foraminotomy with, or without, fusion. For decompression of multiple nerve roots, the procedure at each nerve root is subject to the guidelines of subds. 1. and 2.
1. A health care provider may perform surgical decompression of a cervical nerve root for any of the following diagnoses:
a. Displacement of cervical intervertebral disc, ICD-9-CM code 722.0, excluding fracture.
b. Cervical radiculopathy or radiculitis, ICD-9-CM code 723.4, excluding fracture.
2. Any of the requirements in this subdivision and any of the requirements in subd. 3. shall be satisfied to indicate that surgery is reasonably required. For the response to nonsurgical care, the patient’s condition includes any of the following:
a. Failure to improve with a minimum of 8 weeks of initial nonsurgical care.
b. Cervical compressive myelopathy.
c. Progressive neurologic deficits.
3. The patient exhibits one of the clinical findings of subd. 3. a. in combination with the test results of subd. 3. b.
a. Subjective sensory symptoms in a dermatomal distribution that may include radiating pain, burning, numbness, tingling or paresthesia, or objective clinical findings of nerve root specific motor deficit, reflex changes, or positive electromyography.
b. Medical imaging test results that correlate with the level of nerve root involvement consistent with both the subjective and objective findings.
(d) Lumbar arthrodesis with or without instrumentation. A health care provider may perform surgery for a lumbar arthrodesis when any of the following diagnoses are present to indicate that the surgery is reasonably required:
1. Unstable lumbar vertebral fracture, ICD-9-CM codes 805.4, 805.5, 806.4, and 806.5.
2. For a second or third surgery only, documented reextrusion or redisplacement of lumbar intervertebral disc, ICD-9-CM code 722.10, after previous successful disc surgery at the same level and new lumbar radiculopathy with or without incapacitating back pain, ICD-9-CM code 724.4. Documentation under this subdivision shall include a magnetic resonance imaging scan or computed tomography scan or a myelogram.
3. Traumatic spinal deformity including a history of compression or wedge fracture or fractures, ICD-9-CM code 733.1, and demonstrated acquired kyphosis or scoliosis, ICD-9-CM codes 737.1, 737.10, 737.30, 737.41, and 737.43.
4. Incapacitating low back pain, ICD-9-CM code 724.2, for longer than 3 months, and any of the following conditions involving lumbar segments L-3 and below is present:
a. For the first surgery only, degenerative disc disease, ICD-9-CM code 722.4, 722.5, 722.6, or 722.7, with postoperative documentation of instability created or found at the time of surgery, or positive discogram at one or 2 levels.
b. Pseudoarthrosis, ICD-9-CM code 733.82.
c. For the second or third surgery only, previously operated disc.
d. Spondylolisthesis.
5. A health care provider may not perform a lumbar arthrodesis as the first primary surgical procedure for a new, acute lumbosacral disc herniation with unilateral radiating leg pain in a radicular pattern with or without neurological deficit.
(2) Upper extremity surgery.
(a) General. Initial nonsurgical, surgical, and chronic management guidelines for upper extremity disorders are set forth in s. DWD 81.09 (1) to (16).
(b) Rotator cuff repair. A health care provider may perform rotator cuff surgery for any of the following diagnoses:
1. Rotator cuff syndrome of the shoulder, ICD-9-CM code 726.1, and allied disorders, including unspecified disorders of shoulder bursae and tendons, ICD-9-CM code 726.10; calcifying tendinitis of shoulder, ICD-9-CM code 726.11; bicipital tenosynovitis, ICD-9-CM code 726.12; and other specified disorders, ICD-9-CM code 726.19.
2. Tear of rotator cuff, ICD-9-CM code 727.61.
(c) Criteria and indications for rotator cuff repair. In addition to one of the diagnoses in par. (b), both of the following conditions shall be satisfied to indicate that surgery for rotator cuff repair is necessary:
1. The patient’s condition failed to improve in response to nonsurgical care with adequate initial nonsurgical treatment.
2. The patient’s clinical findings exhibit any of the following:
a. Severe shoulder pain and inability to elevate the shoulder.
b. Weak or absent abduction and tenderness over rotator cuff or pain relief obtained with an injection of anesthetic for diagnostic or therapeutic trial.
c. Positive findings in arthrogram, magnetic resonance imaging scan, or ultrasound, or positive findings on previous arthroscopy, if performed.
(d) Acromioplasty diagnosis. A health care provider may perform acromioplasty for the diagnosis of acromial impingement syndrome, ICD-9-CM codes 726.0 to 726.2. In addition to the diagnosis in this paragraph, both of the following conditions shall be satisfied to indicate that surgery is necessary:
1. The patient’s condition has failed to improve in response to nonsurgical care after adequate initial nonsurgical care.
2. The patient’s clinical findings exhibit pain with active elevation from 90 to 130 degrees, pain at night, and a positive impingement test.
(e) Repair of acromioclavicular or costoclavicular ligaments. A health care provider may perform surgical repair of acromioclavicular or costoclavicular ligaments for the diagnosis of acromioclavicular separation, ICD-9-CM codes 831.04 to 831.14.
1. In addition to the diagnosis in this paragraph, the guidelines in subds. 2. and 3. shall be satisfied for repair of acromioclavicular or costoclavicular ligaments.
2. The patient’s condition or response to nonsurgical care includes any of the following:
a. Failure to improve after at least a one-week trial period in a support brace.
b. Separation cannot be reduced and held in a brace.
c. Grade III separation has occurred.
3. The patient’s clinical findings exhibit localized pain at the acromioclavicular joint and prominent distal clavicle and radiographic evidence of separation at the acromioclavicular joint.
(f) Excision of distal clavicle diagnosis. A health care provider may perform excision of the distal clavicle for any of the following diagnoses specified in subd. 1. to 3.:
1. Acromioclavicular separation, ICD-9-CM codes 831.01 to 831.14.
2. Osteoarthrosis of the acromioclavicular joint, ICD-9-CM codes 715.11, 715.21, and 715.31.
3. Shoulder impingement syndrome.
(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:
1. The patient’s condition failed to improve in response to nonsurgical care with adequate initial nonsurgical care.
2. The patient’s clinical findings exhibit any of the following:
a. Pain at the acromioclavicular joint, with aggravation of pain with motion of shoulder or carrying weight.
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.
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Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published.