Wisconsin Administrative Code › Department of Workforce Development › DWD 80-81 - Worker's Compensation › Chapter DWD 81 - Worker's compensation treatment guidelines › Section DWD 81.12 - Guidelines for surgical procedures

Current through June 24, 2024
(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 co de
				722.10.
b. Sciatica, ICD-9-CM co de
				724.3.
c. Lumbosacral radiculopathy
				or radiculitis, ICD-9-CM co de 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 co de
				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 co de 722.0, excluding fracture.
b. Cervical radiculopathy or radiculitis,
				ICD-9-CM co de 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 co de 722.10, after previous successful disc surgery at the same level
				and new lumbar radiculopathy with or without incapacitating back pain, ICD-9-CM
				co de 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 co de 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 co de 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 co de 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 co de
				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.