Section 81.08. Thoracic back pain.

 

(1)   Diagnostic procedures for treatment of thoracic back injury.

(a) A health care provider shall determine the nature of the thoracic back condition before initiating treatment.

(b) A health care provider shall perform and document an appropriate history and physical examination. Based on the history and physical examination, a health care provider shall assign the patient at each visit to the appropriate clinical category in subds. 1. to 3. 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 in a dermatomal distribution around the chest or abdomen. This section does not apply to fractures of the thoracic spine or thoracic back pain due to an infectious, immunologic, metabolic, endocrine, neurologic, visceral, or neoplastic disease process.

1. Regional thoracic back pain includes the diagnoses of thoracic strain, sprain, myofascial syndrome, musculoligamentous injury, soft tissue injury, and any other diagnosis for pain believed to originate in the discs, ligaments, muscles, or other soft tissues of the thoracic spine and that affects the thoracic region, 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.

2. Radicular pain, with or without regional thoracic back pain, includes the diagnoses of thoracic radiculopathy, radiculitis, or neuritis; displacement or herniation of intervertebral disc with radiculopathy, radiculitis, or neuritis; spinal stenosis with radiculopathy, radiculitis, or neuritis; and any other diagnoses for pain believed to originate with irritation of a nerve root in the thoracic 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.

3. Thoracic 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.

(c) A health care provider may not order laboratory tests in the evaluation of a patient with regional thoracic back pain, or radicular pain, except for any of the following:

1. When a patient's history, age, or examination suggests infection, metabolic-endocrinologic disorders, tumorous conditions, systemic musculoskeletal disorders, such as rheumatoid arthritis or ankylosing spondylitis.

2. To evaluate potential adverse side effects of medications.

3. As part of a preoperative evaluation.

(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.

(e) Medical imaging evaluation of the thoracic 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.

(f) A health care provider may not order electromyography and nerve conduction studies for regional thoracic back pain and radicular pain under par. (b) 1. to 3.

(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 3. :

1. Surface electromyography or surface paraspinal electromyography.

2. Thermography.

3. Plethysmography.

4. Electronic X-ray analysis of plain radiographs.

5. Diagnostic ultrasound of the spine.

6. Somatosensory evoked potentials and motor evoked potentials.

(h) A health care provider may not order computerized range of motion or strength measuring tests during the period of initial nonsurgical care, but may order these tests during a 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 nonoperative care 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.

(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:

1. Is symptom magnification occurring?

2. Does the patient exhibit an emotional reaction to the injury, such as depression, fear, or anger, that is interfering with recovery?

3. Are there other personality factors or disorders that are interfering with recovery?

4. Is the patient chemically dependent?

5. Are there any interpersonal conflicts interfering with recovery?

6. Does the patient have a chronic pain syndrome or psychogenic pain?

7. In cases in which surgery is a possible treatment, are psychological factors likely to interfere with the potential benefit of the surgery?

(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:

1. These procedures are used to localize the source of pain prior to surgery and to diagnose conditions that fail to respond to initial nonoperative care.

2. These blocks and injections are invasive and when done as diagnostic procedures only are not necessary unless noninvasive procedures have failed to establish the diagnosis.

3. Selection of patients, choice of procedure, and localization of the level of injection may be determined by documented clinical findings indicating possible pathologic conditions and the source of pain symptoms.

4. These blocks and injections may also be used as therapeutic modalities and are subject to the guidelines in sub. (5) .

(k) Functional capacity assessment or evaluation is a comprehensive and objective assessment of a 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 and report a patient's physical capacities in general or to determine work tolerance for a specific job, task, or work activity.

1. A functional capacity assessment or evaluation is not necessary during the period of initial nonoperative care.

2. Functional capacity assessment or evaluation is necessary in any of the following circumstances:

a. To identify the patient's permanent activity restrictions and capabilities.

b. To assess the patient's ability to do a specific job.

(L) Consultations with other health care providers may be initiated at any time by a treating health care provider consistent with standard medical practice.

(2)   General treatment guidelines for thoracic back pain.

(a) All medical care for thoracic back pain, appropriately assigned to a category of sub. (1) (b) 1. to 3. 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) , (12) , and (13) as follows:

1. Subsection (11) governs regional thoracic back pain.

2. Subsection (12) governs radicular pain.

3. Subsection (13) governs myelopathy.

(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 may not in itself allow a health care provider to continue a therapy or treatment modality past the maximum duration specified in this section or to repeat a therapy or treatment previously provided for the same injury.

(c) In general, a course of treatment is divided into the following 3 phases:

1. First, all patients with thoracic back problems, except patients with myelopathy under sub. (1) (b) 3. , shall be given initial nonoperative care that may include 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 treatment begins with the first clinical passive, active, injection, durable medical equipment, or medication modality initiated. Initial nonsurgical treatment shall result in progressive improvement as specified in sub. (9) .

2. Second, for patients with persistent symptoms, initial nonsurgical management 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) , (12) , (13) , 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.

a. Patients with myelopathy may require immediate surgical therapy.

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 care.

c. Surgery shall follow the guidelines in subs. (6) , (11) , (12) , (13) , and s. DWD 81.12 (1) .

d. A decision against surgery at any particular time does not preclude a decision for surgery made at a later date in light of new clinical information.

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 also include durable medical equipment as described in sub. (8) .

(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.

(3)   Passive treatment modalities.

(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.

(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 if all of the following apply:

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.

2. The treatment is not given on a regularly scheduled basis.

3. A health care provider documents in the medical record a plan to encourage the patient's independence and decreased reliance on health care providers.

4. Management of the patient's condition includes active treatment modalities during this period.

5. The additional 12 visits for passive treatment does not delay the required surgical or chronic pain evaluation required by this chapter.

6. Passive care is not necessary while the patient has chronic pain syndrome.

(c) Adjustment or manipulation of joints. For purposes of this paragraph, "adjustment or manipulation of joints" includes chiropractic and osteopathic adjustments or manipulations. All of the following guidelines apply to adjustment or manipulation of joints:

1. Time for treatment response is 3 to 5 treatments.

2. Maximum treatment frequency is up to 5 times per week for the first one to 2 weeks decreasing in frequency until the end of the maximum treatment duration period in subd. 3.

3. Maximum treatment duration is 12 weeks.

(d) Thermal treatment. For purposes of this paragraph, "thermal treatment" includes all superficial and deep heating modalities and cooling modalities. Superficial thermal modalities include hot packs, hot soaks, hot water bottles, hydrocollators, heating pads, ice packs, cold soaks, infrared, whirlpool, and fluidotherapy. Deep thermal modalities include diathermy, ultrasound, and microwave. All of the following guidelines apply to thermal treatment:

1. Treatment given in a clinical setting:

a. Time for treatment response is 2 to 4 treatments.

b. Maximum treatment frequency is up to 5 times per week for the first one to 3 weeks decreasing in frequency until the end of the maximum treatment duration period in subd. 1. c.

c. Maximum treatment duration is 12 weeks of treatment in a clinical setting but only if given in conjunction with other therapies.

2. Home use of thermal modalities may be prescribed at any time during the course of treatment. Home use may only involve hot packs, hot soaks, hot water bottles, hydrocollators, heating pads, ice packs, and cold soaks that can be applied by the patient without health care provider assistance. Home use of thermal modalities may not require any special training or monitoring, other than that usually provided by a health care provider during an office visit.

(e) Electrical muscle stimulation. For purposes of this paragraph "electrical muscle stimulation" includes galvanic stimulation, transcutaneous electrical nerve stimulation, interferential, and microcurrent techniques. All of the following guidelines apply to electrical muscle stimulation:

1. Electrical muscle stimulation given in a clinical setting:

a. Time for treatment response is 2 to 4 treatments.

b. Maximum treatment frequency is up to 5 times per week for the first one to 3 weeks decreasing in frequency until the end of the maximum treatment duration period in subd. 1. c.

c. Maximum treatment duration is 12 weeks of treatment in a clinical setting but only if given in conjunction with other therapies.

2. Home use of an electrical stimulation device may be prescribed at any time during a course of treatment. Initial use of an electrical stimulation device shall be in a supervised setting in order to ensure proper electrode placement and patient education. All of the following guidelines apply to home use of an electrical stimulation device:

a. Maximum time for patient education and training is up to 3 sessions.

b. Patient may use the electrical stimulation device for one month, at which time effectiveness of the treatment shall be reevaluated by a health care provider before continuing home use of the device.

(f) Mechanical traction. All of the following guidelines apply to mechanical traction:

1. Treatment given in a clinical setting:

a. Time for treatment response is 3 treatments.

b. Maximum treatment frequency is up to 3 times per week for the first one to 3 weeks decreasing in frequency until the end of the maximum treatment duration period in subd. 1. c.

c. Maximum treatment duration is 12 weeks in a clinical setting but only if used in conjunction with other therapies.

2. Home use of a mechanical traction device may be prescribed as follow-up to use of traction in a clinical setting if it has proven to be effective treatment and is expected to continue to be effective treatment. Initial use of a mechanical traction device shall be in a supervised setting in order to ensure proper patient education. All of the following guidelines apply to home use of a mechanical traction device:

a. Maximum time for patient education and training is one session.

b. A patient may use the mechanical traction device for one month, at which time effectiveness of the treatment shall be reevaluated by a health care provider before continuing home use of the device.

(g) Acupuncture treatments. For purposes of this paragraph, "acupuncture treatments" include endorphin-mediated analgesic therapy that includes classic acupuncture and acupressure. All of the following guidelines apply to acupuncture treatments:

1. Time for treatment response is 3 to 5 sessions.

2. Maximum treatment frequency is up to 3 times per week for one to 3 weeks and decreasing in frequency until the end of the maximum treatment duration period in subd. 3.

3. Maximum treatment duration is 12 weeks.

(h) Manual therapy. For purposes of this paragraph, "manual therapy" includes soft tissue and joint mobilization, therapeutic massage, and manual traction. All of the following guidelines apply to manual therapy:

1. Time for treatment response is 3 to 5 treatments.

2. Maximum treatment frequency is up to 5 times per week for the first one to 2 weeks decreasing in frequency until the end of the maximum treatment duration period in subd. 3.

3. Maximum treatment duration is 12 weeks.

(i) Phoresis. For purposes of this paragraph, "phoresis" includes iontophoresis and phonophoresis. All of the following guidelines apply to phoresis:

1. Time for treatment response is 3 to 5 sessions.

2. Maximum treatment frequency is up to 3 times per week for the first one to 3 weeks and decreasing in frequency until the end of the maximum treatment duration period in subd. 3.

3. Maximum treatment duration is 12 weeks.

(j) Bedrest. Prolonged restriction of activity and immobilization are detrimental to a patient's recovery. Bedrest may not be prescribed for more than 7 days.

(k) Spinal braces and other movement restricting appliances. Spinal braces and other movement-restricting appliances required for longer than 2 weeks shall be accompanied by active muscle strengthening exercise to avoid deconditioning and prolonged disability. All of the following guidelines apply to spinal braces and other movement-restricting appliances:

1. Time for treatment response is 3 days.

2. Maximum treatment frequency is limited to intermittent use during times of increased physical stress or prophylactic use at work.

3. Maximum continuous duration is 3 weeks unless patient is status postfusion.

(4)   Active treatment modalities.

(a) Active treatment modalities shall be used as set forth in pars. (b) to (f) . A health care provider's use of active treatment modalities may extend past the 12-week limit on passive treatment modalities, so long as the maximum durations for the active treatment modalities are not exceeded.

(b) Education shall teach the patient about pertinent anatomy and physiology as it relates to spinal function for the purpose of injury prevention. Education includes training on posture, biomechanics, and relaxation. The maximum number of treatments is 3 visits, which include an initial education and training session and 2 follow-up visits.

(c) Posture and work method training shall instruct the patient in the proper performance of job activities. Topics include proper positioning of the trunk, back and arms, use of optimum biomechanics in performing job tasks, and appropriate pacing of activities. Methods may include didactic sessions, demonstrations, exercises, and simulated work tasks. The maximum number of treatments is 3 visits.

(d) Worksite analysis and modification shall examine the patient's work station, tools, and job duties. A health care provider may make recommendations for the alteration of the work station, selection of alternate tools, modification of job duties, and provision of adaptive equipment. The maximum number of treatments is 3 visits.

(e) Exercise, which is important to the success of an initial nonsurgical treatment program and a return to normal activity, shall include active patient participation in activities designed to increase flexibility, strength, endurance, or muscle relaxation. Exercise shall, at least in part, be specifically aimed at the musculature of the thoracic spine. Aerobic exercise and extremity strengthening may be performed as adjunctive treatment but may not be the primary focus of the exercise program.

(f) Exercises shall be evaluated to determine if the desired goals are being attained. Strength, flexibility, and endurance shall be objectively measured. A health care provider may objectively measure the treatment response as often as necessary for optimal care after the initial evaluation. Subdivisions 1. and 2. govern supervised and unsupervised exercise, except for computerized exercise programs and health clubs, which are governed by s. DWD 81.13 .

1. `Guidelines for supervised exercise.' One goal of an exercise program shall be to teach the patient how to maintain and maximize any gains experienced from exercise. Self-management of the condition shall be promoted. All of the following guidelines apply to supervised exercise:

a. Maximum treatment frequency is 3 times per week for 3 weeks and may decrease with time until the end of the maximum treatment duration period in subd. 1. b.

b. Maximum duration is 12 weeks.

2. `Guidelines for unsupervised exercise.' Unsupervised exercise shall be provided in the least intensive setting appropriate to the goals of the exercise program and may supplement or follow the period of supervised exercise. All of the following guidelines apply to unsupervised exercise:

a. Maximum treatment frequency is one to 3 visits for instruction and monitoring.

b. There is no limit on the duration and frequency of exercise at home.

(5)   Therapeutic injections.

(a) Injection modalities are necessary as set forth in pars. (b) to (d) . A health care provider's use of injections may extend past the 12-week limit on passive treatment modalities, so long as the maximum treatment for injections is not exceeded.

(b) For purposes of this subsection, "therapeutic injections" include trigger points injections, facet joint injections, facet nerve blocks, sympathetic nerve blocks, epidurals, nerve root blocks, and peripheral nerve blocks. Therapeutic injections may only be given in conjunction with active treatment modalities directed to the same anatomical site.

1. All of the following guidelines apply to trigger point injections:

a. Time for treatment response is within 30 minutes.

b. Maximum treatment frequency is once per week if there is a positive response to the first injection at that site. If subsequent injections at that site demonstrate diminishing control of symptoms or fail to facilitate objective functional gains, then trigger point injections shall be redirected to other areas or discontinued. Only 3 injections per patient visit.

c. Maximum treatment is 4 injections to any one site.

2. All of the following guidelines apply to facet joint injections and facet nerve blocks:

a. Time for treatment response is within one week.

b. Maximum treatment frequency is once every 2 weeks if there is a positive response to the first injection or block. If subsequent injections or blocks demonstrate diminishing control of symptoms or fail to facilitate objective functional gains, then injections or blocks shall be discontinued. Only 3 injections or blocks per patient visit.

c. Maximum treatment is 3 injections or blocks to any one site.

3. All of the following guidelines apply to nerve root blocks:

a. Time for treatment response is within one week.

b. Maximum treatment frequency may permit repeat injection 2 weeks after the previous injection if there is a positive response to the first block. Only 3 injections per patient visit.

c. Maximum treatment is 2 blocks to any one site.

4. All of the following guidelines apply to epidural injections:

a. Time for treatment response is within one week.

b. Maximum treatment frequency is once every 2 weeks if there is a positive response to the first injection. If subsequent injections demonstrate diminishing control of symptoms or fail to facilitate objective functional gains, then injections shall be discontinued. Only one injection per patient visit.

c. Maximum treatment is 3 injections.

(c) For purposes of this paragraph, "lytic or sclerosing injections" include radio frequency denervation of the facet joints. These injections may only be given in conjunction with active treatment modalities directed to the same anatomical site. All of the following guidelines apply to lytic or sclerosing injections:

1. Time for treatment response is within one week.

2. Optimum treatment frequency may repeat once for any site.

3. Maximum duration is 2 injections to any one site.

(d) Prolotherapy and botulinum toxin injections are not necessary in the treatment of thoracic back problems.

(6)   Surgery including decompression procedures.

(a) A health care provider may perform surgery only if it meets the specific guidelines of subs. (11) , (12) , (13) , and s. DWD 81.12 (1) .

(b) In order to optimize the beneficial effect of surgery, postoperative therapy with active and passive treatment modalities may be provided, even if these modalities had been used in the preoperative treatment of the condition. In the postoperative period the maximum treatment duration with passive treatment modalities in a clinical setting from the initiation of the first passive modality used, except bedrest or bracing, is as follows:

1. Eight weeks following decompression or implantation of a spinal cord stimulator or intrathecal drug delivery system.

2. Twelve weeks following arthrodesis.

(c) Repeat surgery shall also meet the guidelines of subs. (11) , (12) , (13) , and s. DWD 81.12 (1) .

(d) The surgical therapies in subds. 1. and 2. have very limited application and require a personality or psychosocial evaluation that indicates the patient is likely to benefit from the treatment.

1. Spinal cord stimulator may be necessary for a patient who has neuropathic pain and has had a favorable response to a trial screening period.

2. Intrathecal drug delivery system may be necessary for a patient who has somatic or neuropathic pain and has had a favorable response to a trial screening period.

(7)   Chronic management. Chronic management of thoracic back pain shall be provided according to the guidelines of s. DWD 81.13 .

(8)   Durable medical equipment.

(a) A health care provider may direct the use of durable medical equipment only in certain specific situations as specified in pars. (b) to (e) .

(b) Braces or supports may be necessary within the guidelines of sub. (3) (k) .

(c) For patients using electrical muscle stimulation or mechanical traction devices at home, the device and any required supplies are necessary within the guidelines of sub. (3) (e) and (f) .

(d) Exercise equipment for home use, including bicycles, treadmills, and stairclimbers, are necessary only as part of an approved chronic management program. This equipment is not necessary during initial nonoperative care or during reevaluation and surgical therapy. If the employer has an appropriate exercise facility on its premises with the prescribed equipment, the insurer may mandate the use of that facility instead of authorizing purchase of equipment for home use.

1. `Indications.' The patient is deconditioned and requires reconditioning that may be accomplished only with the use of the prescribed exercise equipment. A health care provider shall document specific reasons why the exercise equipment is necessary and may not be replaced with other activities.

2. `Requirements.' The use of the equipment shall have specific goals and there shall be a specific set of prescribed activities.

(e) All of the following durable medical equipment is not necessary for home use for thoracic back pain conditions:

1. Whirlpools, Jacuzzis, hot tubs, or special bath or shower attachments.

2. Beds, waterbeds, mattresses, chairs, recliners, or loungers.

(9)   Evaluation of treatment by health care provider.

(a) A health care provider shall evaluate at each visit whether the treatment is medically necessary and shall evaluate whether initial nonsurgical management is effective according to pars. (b) to (e) . No later than the time for treatment response established for the specific modality in subs. (3) to (5) , a health care provider shall evaluate whether the passive, active, injection, or medication treatment modality is resulting in progressive improvement in pars. (b) to (e) .

(b) 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.

(c) 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.

(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.

(e) If there is not progressive improvement in at least 2 categories 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.

(10)   Medication management.

(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 thoracic back pain.

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

(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.

(11)   Specific treatment guidelines for regional thoracic back pain.

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

1. The active, passive, 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.

2. The only therapeutic injections necessary for patients with regional thoracic back pain are trigger point injections, facet joint injections, facet nerve blocks, and epidural blocks, and their use shall meet the guidelines of sub. (5) .

3. After the first week of treatment, initial nonsurgical management shall at all times contain active treatment modalities according to the guidelines of sub. (4) .

4. Initial nonsurgical treatment shall be provided in the least intensive setting consistent with quality health care practices.

5. Except as provided 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.

(b) Surgical evaluation or chronic management is necessary if the patient continues with symptoms and objective 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.

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 surgical therapy does not preclude surgery at a later date.

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.

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) .

4. Surgical evaluation may also include personality or psychosocial evaluation, consistent with the guidelines of sub. (1) (i) .

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 objective physical findings.

6. The only surgical procedure necessary for patients with regional thoracic back pain only is thoracic arthrodesis with or without instrumentation, which shall meet the guidelines of sub. (6) and s. DWD 81.12 (1) (d) . For patients with failed surgery, spinal cord stimulators or intrathecal drug delivery systems may be necessary consistent with sub. (6) (d) .

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.

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.

(c) If the patient continues with symptoms and objective physical findings after surgery has been rendered, 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 under s. DWD 81.13 .

(12)   Specific treatment guidelines for radicular pain.

(a) Initial nonsurgical treatment is appropriate for all patients with radicular pain 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 thoracic back pain, therapeutic facet joint injections, facet nerve blocks, and trigger point injections may also be necessary.

(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) , with the following modifications: The only surgical procedures necessary for patients with radicular pain are decompression or arthrodesis. For patients with failed surgery, spinal cord stimulators or intrathecal drug delivery systems may be necessary consistent with sub. (6) (d) .

(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 thoracic back pain shall be provided under the guidelines of s. DWD 81.13 .

(13)   Specific treatment guidelines for myelopathy.

(a) Patients with myelopathy may require emergency surgical evaluation at any time during the course of their overall treatment. The health care provider may decide to proceed with surgical evaluation 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 nonsurgical treatments. Surgery, if necessary, may be performed at any time during the course of treatment. Surgical evaluation and surgery shall be within the guidelines of sub. (11) (b) , with the following modifications:

1. Surgical evaluation and surgical therapy may begin at any time.

2. The only surgical procedures necessary for patients with myelopathy are decompression and arthrodesis. For patients with failed surgery, spinal cord stimulators or intrathecal drug delivery systems may be necessary consistent with sub. (6) (d) .

(b) If the health care provider decides to proceed with a course of nonsurgical care for a patient with myelopathy, it shall follow the guidelines of sub. (12) (a) .

(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 myelopathy shall be provided under the guidelines of s. DWD 81.13 .

CR 07-019 : cr. Register October 2007 No. 622 , eff. 11-1-07.