DWD 81.06(11)(11) Specific treatment guidelines for regional low back pain. 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)4.4. Initial nonsurgical treatment shall be provided in the least intensive setting consistent with quality health care practices. 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)4.4. Surgical evaluation may also include personality or psychosocial evaluation, consistent with the guidelines of sub. (1) (i). 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)(12) Specific treatment guidelines for radicular pain, with or without regional low back pain, with no or static neurologic deficits. 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. DWD 81.06(13)(b)(b) If a health care provider decides to proceed with a course of initial nonsurgical care for a patient with radicular pain with progressive neurologic changes, it shall follow the guidelines of sub. (12) (a). DWD 81.06(13)(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. Any course or program of chronic management for patients with radicular pain, with or without regional low back pain, with foot drop or progressive neurologic changes at first presentation shall be provided under the guidelines of s. DWD 81.13. DWD 81.06 HistoryHistory: CR 07-019: cr. Register October 2007 No. 622, eff. 11-1-07. DWD 81.07(1)(1) Diagnostic procedures for treatment of neck injury. DWD 81.07(1)(a)(a) A health care provider shall determine the nature of the neck condition before initiating treatment. DWD 81.07(1)(b)(b) A health care provider shall perform and document an appropriate history and physical examination. Based on the history and physical examination the health care provider shall assign the patient at each visit to the appropriate clinical category in subds. 1. to 4. A health care provider shall document the diagnosis in the medical record. For the purposes of subds. 2. and 3., “radicular pain” means pain radiating distal to the shoulder. This section does not apply to fractures of the cervical spine or cervical pain due to an infectious, immunologic, metabolic, endocrine, neurologic, visceral, or neoplastic disease process. DWD 81.07(1)(b)1.1. Regional neck pain includes referred pain to the shoulder and upper back. Regional neck pain includes the diagnoses of cervical strain, sprain, myofascial syndrome, musculoligamentous injury, soft tissue injury, and other diagnoses for pain believed to originate in the discs, ligaments, muscles, or other soft tissues of the cervical spine and that affects the cervical region, with or without referral to the upper back or shoulder, including ICD-9-CM codes 720 to 720.9, 721 to 721.0, 721.5 to 721.90, 722.3 to 722.30, 722.4, 722.6, 722.9 to 722.91, 723 to 723.3, 723.5 to 723.9, 724.5, 724.8, 724.9, 732.0, 737 to 737.9, 738.4, 738.5, 739.1, 756.1 to 756.19, 847 to 847.0, 920, 922.3, 925, and 926.1 to 926.12. DWD 81.07(1)(b)2.2. Radicular pain, with or without regional neck pain, with no or static neurologic deficit includes the diagnoses of brachialgia, cervical radiculopathy, radiculitis, or neuritis; displacement or herniation of intervertebral disc with radiculopathy, radiculitis, or neuritis; spinal stenosis with radiculopathy, radiculitis, or neuritis; and other diagnoses for pain in the arm distal to the shoulder believed to originate with irritation of a nerve root in the cervical spine, including ICD-9-CM codes 721.1, 721.91, 722 to 722.0, 722.2, 722.7 to 722.71, 723.4, and 724 to 724.00. In these cases neurologic findings on history and examination are either absent or do not show progressive deterioration. DWD 81.07(1)(b)3.3. Radicular pain, with or without regional neck pain, with progressive neurologic deficit, includes the same diagnoses as subd. 2., except in these cases there is a history of progressive deterioration in the neurologic symptoms and physical findings, including worsening sensory loss, increasing muscle weakness, and progressive reflex changes. DWD 81.07(1)(b)4.4. Cervical compressive myelopathy, with or without radicular pain, is a condition characterized by weakness and spasticity in one or both legs and associated with any of the following: exaggerated reflexes, an extensor plantar response, bowel or bladder dysfunction, sensory ataxia, or bilateral sensory changes. DWD 81.07(1)(c)(c) A health care provider may not order laboratory tests in the evaluation of a patient with regional neck pain, or radicular pain, except for any of the following: DWD 81.07(1)(c)1.1. When a patient’s history, age, or examination suggests infection, metabolic-endocrinologic disorders, tumorous conditions, or systemic musculoskeletal disorders, such as rheumatoid arthritis or ankylosing spondylitis. DWD 81.07(1)(d)(d) Laboratory tests may be ordered at any time a health care provider suspects any of the conditions specified in par. (c), but a health care provider shall justify the need for the tests ordered with clear documentation of the indications. DWD 81.07(1)(e)(e) Medical imaging evaluation of the cervical spine shall be based on the findings of the history and physical examination and may not be ordered prior to a health care provider’s clinical evaluation of the patient. Medical imaging may not be performed as a routine procedure and shall comply with the guidelines in s. DWD 81.05. A health care provider shall document the appropriate indications for any medical imaging studies obtained. DWD 81.07(1)(f)(f) Electromyography and nerve conduction studies are always inappropriate for the regional neck pain diagnoses in par. (b) 1. to 4. Electromyography and nerve conduction studies may be an appropriate diagnostic tool for radicular pain and myelopathy diagnoses in par. (b) 2. to 4., after the first 3 weeks of radicular or myelopathy symptoms. Repeat electromyography and nerve conduction studies for radicular pain and myelopathy are not necessary unless a new neurologic symptom or finding has developed which in itself would warrant electrodiagnostic testing. Failure to improve with treatment is not an indication for repeat testing. DWD 81.07(1)(g)(g) A health care provider may not order the use of any of the following procedures or tests for the diagnosis of any of the clinical categories in par. (b) 1. to 4.: DWD 81.07(1)(h)(h) A health care provider may not order computerized range of motion or strength measuring tests during the period of initial nonsurgical management, but may order these tests during the period of chronic management when used in conjunction with a computerized exercise program, work hardening program, or work conditioning program. During the period of initial nonsurgical management, computerized range of motion or strength testing may be performed but shall be done in conjunction with an office visit with a health care provider’s evaluation or treatment, or physical or occupational therapy evaluation or treatment. DWD 81.07(1)(i)(i) A health care provider may order personality or psychological evaluations for evaluating patients who continue to have problems despite appropriate care. A treating health care provider may perform this evaluation or may refer the patient for consultation with another health care provider in order to obtain a psychological evaluation. These evaluations may be used to assess the patient for a number of psychological conditions that may interfere with recovery from the injury. Since more than one of these psychological conditions may be present in a given case, a health care provider performing the evaluation shall consider all of the following: DWD 81.07(1)(i)2.2. Does the patient exhibit an emotional reaction to the injury, such as depression, fear, or anger, that is interfering with recovery? DWD 81.07(1)(i)3.3. Are there other personality factors or disorders that are interfering with recovery? DWD 81.07(1)(i)6.6. Does the patient have a chronic pain syndrome or psychogenic pain? DWD 81.07(1)(i)7.7. In cases in which surgery is a possible treatment, are psychological factors likely to interfere with the potential benefit of the surgery? DWD 81.07(1)(j)(j) All of the following are guidelines for diagnostic analgesic blocks or injection studies and include facet joint injection, facet nerve block, epidural differential spinal block, nerve block, and nerve root block. DWD 81.07(1)(j)1.1. These procedures are used to localize the source of pain prior to surgery and to diagnose conditions that fail to respond to initial nonsurgical management. DWD 81.07(1)(j)2.2. These blocks and injections are invasive and when done as diagnostic procedures are not necessary unless noninvasive procedures have failed to establish the diagnosis. DWD 81.07(1)(j)3.3. Selection of patients, choice of procedure, and localization of the level of injection shall be determined by documented clinical findings indicating possible pathologic conditions and the source of pain symptoms. DWD 81.07(1)(j)4.4. These blocks and injections may also be used as therapeutic modalities and are subject to the guidelines in sub. (5) DWD 81.07(1)(k)(k) Functional capacity assessment or evaluation is a comprehensive and objective assessment of patient’s ability to perform work tasks. The components of a functional capacity assessment or evaluation include neuromusculoskeletal screening, tests of manual material handling, assessment of functional mobility, and measurement of postural tolerance. A functional capacity assessment or evaluation is an individualized testing process and the component tests and measurements are determined by the patient’s condition and the requested information. Functional capacity assessments and evaluations are performed to determine a patient’s physical capacities in general or to determine and report work tolerance for a specific job, task, or work activity. DWD 81.07(1)(k)1.1. Functional capacity assessment or evaluation is not necessary during the period of initial nonoperative care. DWD 81.07(1)(k)2.2. Functional capacity assessment or evaluation is necessary in any of the following circumstances: DWD 81.07(1)(k)2.a.a. To identify the patient’s permanent activity restrictions and capabilities. DWD 81.07(1)(L)(L) Consultations with other health care providers may be initiated at any time by a treating health care provider consistent with accepted medical practice. DWD 81.07(2)(a)(a) All medical care for neck pain appropriately assigned to a clinical category in sub. (1) (b) is determined by the diagnosis and clinical category that the patient has been assigned. General guidelines for treatment modalities are set forth in subs. (3) to (10). Specific treatment guidelines for each clinical category are set forth in subs. (11) to (14) as follows: DWD 81.07(2)(b)(b) A health care provider shall at each visit reassess the appropriateness of the clinical category assigned and reassign the patient if warranted by new clinical information including symptoms, signs, results of diagnostic testing and opinions, and information obtained from consultations with other health care providers. When the clinical category is changed the treatment plan shall be appropriately modified to reflect the new clinical category. A change of clinical category shall not in itself allow a health care provider to continue a therapy or treatment modality past the maximum duration specified in subs. (3) to (10) or to repeat a therapy or treatment previously provided for the same injury. DWD 81.07(2)(c)(c) In general, a course of treatment is divided into the following 3 phases: DWD 81.07(2)(c)1.1. First, all patients with neck problems, except patients with radicular pain with progressive neurological deficit or myelopathy under sub. (1) (b) 3. and 4., shall be given initial nonsurgical care that may include both active and passive treatment modalities, injections, durable medical equipment, and medications. These modalities and guidelines are described in subs. (3), (4), (5), (8), and (10). The period of initial nonsurgical management begins with the first passive, active, injection, durable medical equipment, or medication modality initiated. Initial nonsurgical treatment shall result in progressive improvement as specified in sub. (9). DWD 81.07(2)(c)2.2. Second, for patients with persistent symptoms, initial nonoperative care is followed by a period of surgical evaluation. This evaluation shall be completed in a timely manner. Surgery, if necessary, shall be performed as expeditiously as possible consistent with sound medical practice and subs. (6), (11) to (14), and s. DWD 81.12 (1). A treating health care provider may do the evaluation or may refer the patient to another health care provider. DWD 81.07(2)(c)2.a.a. Patients with radicular pain with progressive neurological deficit or myelopathy may require immediate surgical therapy. DWD 81.07(2)(c)2.b.b. Any patient who has had surgery may require postoperative therapy with active and passive treatment modalities. This therapy may be in addition to any received during the period of initial nonsurgical management. DWD 81.07(2)(c)2.d.d. A decision against surgery at any particular time does not preclude a decision for surgery made at a later date. DWD 81.07(2)(c)3.3. Third, for those patients who are not candidates for or refuse surgical therapy, or who do not have complete resolution of their symptoms with surgery, a period of chronic management may be necessary. Chronic management modalities are described in s. DWD 81.13 and may include durable medical equipment as described in sub. (8). DWD 81.07(2)(d)(d) A treating health care provider may refer the patient for a consultation at any time during the course of treatment consistent with accepted medical practice. DWD 81.07(3)(a)(a) General. Except as set forth in par. (b) or s. DWD 81.04 (5), a health care provider may not direct the use of passive treatment modalities in a clinical setting as set forth in pars. (c) to (i) beyond 12 calendar weeks after any of the passive modalities in pars. (c) to (i) are initiated. There are no limitations on the use of passive treatment modalities by the patient at home. DWD 81.07(3)(b)(b) Additional passive treatment modalities. A health care provider may direct an additional 12 visits for the use of passive treatment modalities over an additional 12 months to be provided if all of the following apply: DWD 81.07(3)(b)1.1. The patient is released to work or is permanently totally disabled and the additional passive treatment shall result in progressive improvement in, or maintenance of, functional status achieved during the initial 12 weeks of passive care.
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