Section 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.

c. Separation at the acromioclavicular joint with weight-bearing films or severe degenerative joint disease at the acromioclavicular joint noted on X-rays.

(h) Repair of shoulder dislocation or subluxation, any procedure.

1. A health care provider may perform surgical repair of a shoulder dislocation for any of the following diagnoses:

a. Recurrent dislocations, ICD-9-CM code 718.31.

b. Recurrent subluxations.

c. Persistent instability following traumatic dislocation.

2. In addition to one of the diagnoses in this paragraph, all of the following clinical findings shall exist for repair of a shoulder dislocation:

a. The patient exhibits a history of multiple dislocations or subluxations that inhibit activities of daily living.

b. X-ray findings are consistent with multiple dislocations or subluxations.

(i) Repair of proximal biceps tendon.

1. A health care provider may perform surgical repair of a proximal biceps tendon for the diagnosis of proximal rupture of the biceps, ICD-9-CM code 727.62 or 840.8.

2. In addition to the diagnosis in subd. 1. , both of the following conditions shall be satisfied for repair of proximal biceps tendon:

a. The procedure may be done alone or in conjunction with another necessary repair of the rotator cuff.

b. The patient's clinical findings exhibit pain that does not resolve with attempt to use arm and palpation of "bulge" in upper aspect of arm.

(j) Epicondylitis. Specific guidelines for surgery for epicondylitis are included in s. DWD 81.09 (11) .

(k) Tendinitis. Specific guidelines for surgery for tendinitis are included in s. DWD 81.09 (12) .

(L) Nerve entrapment syndromes. Specific guidelines for nerve entrapment syndromes are included in s. DWD 81.09 (13) .

(m) Muscle pain syndromes. Surgery is not necessary for muscle pain syndromes.

(n) Traumatic sprains and strains. Surgery is not necessary for the treatment of traumatic sprains and strains, unless there is clinical evidence of complete tissue disruption. Patients with complete tissue disruption may need immediate surgery.

(3)   Lower extremity surgery.

(a) Anterior cruciate ligament reconstruction.

1. A health care provider may perform surgical repair of the anterior cruciate ligament, including arthroscopic repair, for any of the following diagnoses:

a. Old disruption of anterior cruciate ligament, ICD-9-CM code 717.83.

b. Sprain of cruciate ligament of knee, ICD-9-CM code 844.2.

2. In addition to one of the diagnoses in this paragraph, all of the conditions in subd. 2. a. to c. shall be satisfied for anterior cruciate ligament reconstruction. Pain alone is not an indication.

a. The patient gives a history of instability of the knee described as "buckling or giving way" with significant effusion at time of injury, or description of injury indicates a rotary twisting or hyperextension occurred.

b. There are objective clinical findings of positive Lachman's sign, positive pivot shift, or positive anterior drawer.

c. There are positive diagnostic findings with arthrogram, magnetic resonance imaging scan, or arthroscopy, and there is no evidence of severe compartmental arthritis.

(b) Patellar tendon realignment.

1. A health care provider may perform patellar tendon realignment for the diagnosis of dislocation of patellar, open, ICD-9-CM code 836.3; or closed, ICD-9-CM code 836.4; or chronic residuals of dislocation.

2. In addition to the diagnosis in this paragraph, all of the following conditions shall be satisfied for a patellar tendon realignment:

a. The patient gives a history of rest pain as well as pain with patellofemoral movement, and recurrent effusion, or recurrent dislocation.

b. There are objective clinical findings of patellar apprehension, synovitis, lateral tracking, or Q angle greater than 15 degrees.

(c) Knee joint replacement.

1. A health care provider may perform a knee joint replacement for degeneration of articular cartilage or meniscus of knee, ICD-9-CM codes 717.1 to 717.4.

2. In addition to the diagnosis in this paragraph, all of the following conditions shall be satisfied for a knee joint replacement:

a. The patient exhibits limited range of motion, night pain in the joint, or pain with weight-bearing, and no significant relief of pain with an adequate course of initial nonsurgical care.

b. The patient's diagnostic findings confirm there is significant loss or erosion of cartilage to the bone, and positive findings of advanced arthritis, and joint destruction with standing films, magnetic resonance imaging scan, or arthroscopy.

(d) Fusion; ankle, tarsal, metatarsal.

1. A health care provider may perform an ankle, tarsal, or metatarsal fusion for either of the following diagnoses:

a. Malunion or nonunion of fracture of ankle, tarsal, or metatarsal, ICD-9-CM code 733.81 or 733.82.

b. Traumatic arthritis, arthropathy, ICD-9-CM code 716.17.

2. In addition to one of the diagnoses in this paragraph, the following conditions shall be satisfied for an ankle, tarsal, or metatarsal fusion. For initial nonsurgical care the patient shall have failed to improve with an adequate course of initial nonsurgical care that included any of the following:

a. Immobilization, which may include casting, bracing, shoe modification, or other orthotics.

b. Anti-inflammatory medications.

3. The patient's clinical findings exhibit both of the following and subd. 4. :

a. The patient gives a history of pain which is aggravated by activity and weight-bearing, and relieved by xylocaine injection.

b. There are objective findings on physical examination of malalignment or specific joint line tenderness, and decreased range of motion.

4. The patient's diagnostic findings include medical imaging studies confirming the presence of any of the following:

a. Loss of articular cartilage and joint space narrowing.

b. Bone deformity with hypertrophic spurring and sclerosis.

c. Nonunion or malunion of a fracture.

(e) Lateral ligament ankle reconstruction.

1. A health care provider may perform ankle reconstruction surgery involving the lateral ligaments for any of the following diagnoses:

a. Chronic ankle instability, ICD-9-CM code 718.87.

b. Grade III sprain, ICD-9-CM codes 845.0 to 845.09.

2. In addition to one of the diagnoses in subd. 1. , all of the clinical findings in subd. 3. shall be satisfied for a lateral ligament ankle reconstruction. For initial nonsurgical care, the patient shall have received an adequate course of initial nonsurgical care, including one of the following:

a. Immobilization with support, cast, or ankle brace.

b. A physical rehabilitation program that follows immobilization with support, cast, or ankle brace.

3. The patient's clinical findings shall include all of the following:

a. The patient gives a history of ankle instability and swelling.

b. There is a positive anterior drawer sign on examination.

c. There are positive stress X-rays identifying motion at ankle or subtalar joint with at least a 15 degree lateral opening at the ankle joint, or demonstrable subtalar movement, and negative to minimal arthritic joint changes on X-ray, or ligamentous injury is shown on magnetic resonance imaging scan.

4. Prosthetic ligaments are not necessary for the treatment of lateral ligament ankle reconstruction.

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