Current through Register Vol. 48, No. 39, March 25, 2024
Subpart
1.
Diagnostic procedures for treatment of low back
injury.
A health care provider shall determine the nature of the
condition before initiating treatment.
A. An appropriate history and physical
examination must be performed and documented. Based on the history and physical
examination the health care provider must assign the patient at each visit to
the appropriate clinical category according to subitems (1) to (4). The
diagnosis must be documented in the medical record. For the purposes of
subitems (2) and (3), "radicular pain" means pain radiating distal to the knee,
or pain conforming to a dermatomal distribution and accompanied by anatomically
congruent motor weakness or reflex changes. This part does not apply to
fractures of the lumbar spine, or back pain due to an infectious, immunologic,
metabolic, endocrine, neurologic, visceral, or neoplastic disease process. For
treatment on or after October 1, 2015, an ICD-10-CM code that is equivalent to
an applicable ICD-9-CM code listed in this item must be used instead of the
ICD-9-CM code. The General Equivalence Mappings tool established by the Centers
for Medicare and Medicaid Services must be used to determine the equivalent
ICD-10-CM code or codes.
(1) Regional low
back pain, includes referred pain to the leg above the knee unless it conforms
to an L2, L3, or L4 dermatomal distribution and is accompanied by anatomically
congruent motor weakness or reflex changes. Regional low back pain includes the
diagnoses of lumbar, lumbosacral, or sacroiliac: strain, sprain, myofascial
syndrome, musculoligamentous injury, soft tissue injury, spondylosis, and other
diagnoses for pain believed to originate in the discs, ligaments, muscles, or
other soft tissues of the lumbar spine or sacroiliac joints and which effects
the lumbosacral region, with or without referral to the buttocks and/or leg
above the knee, including, but not limited to, ICD-9-CM codes 720 to 720.9,
721, 721.3, 721.5 to 721.90, 722, 722.3, 722.32, 722.5, 722.51, 722.52, 722.6,
722.8, 722.80, 722.83, 722.9, 722.90, 722.93, 724.2, 724.5, 724.6, 724.8,
724.9, 732.0, 737 to 737.9, 738.4, 738.5, 739.2 to 739.4, 756.1 to 756.19,
846.0, 847.2 to 847.9, 922.3, 922.31, 926.1, 926.11, and 926.12.
(2) Radicular pain, with or without regional
low back pain, with static or no neurologic deficit. This includes the
diagnoses of sciatica; lumbar or lumbosacral radiculopathy, radiculitis or
neuritis; displacement or herniation of intervertebral disc with myelopathy,
radiculopathy, radiculitis or neuritis; spinal stenosis with myelopathy,
radiculopathy, radiculitis or neuritis; and any other diagnoses for pain in the
leg below the knee believed to originate with irritation of a nerve root in the
lumbar spine, including, but not limited to, the ICD-9-CM codes 721.4, 721.42,
721.91, 722.1, 722.10, 722.11, 722.2, 722.7, 722.73, 722.8, 722.80, 722.83,
724.0, 724.00, 724.02, 724.09, 724.3, 724.4, and 724.9. In these cases,
neurologic findings on history and physical examination are either absent or do
not show progressive deterioration.
(3) Radicular pain, with or without regional
low back pain, with progressive neurologic deficit. This includes the same
diagnoses as subitem (2), however, this category applies when there is a
history of progressive deterioration in the neurologic symptoms and physical
findings which include worsening sensory loss, increasing muscle weakness, or
progressive reflex changes.
(4)
Cauda equina syndrome, which is a syndrome characterized by anesthesia in the
buttocks, genitalia, or thigh and accompanied by disturbed bowel and bladder
function, ICD-9-CM codes 344.6, 344.60, and 344.61.
B. Laboratory tests are not indicated in the
evaluation of a patient with regional low back pain, radicular pain, or cauda
equina syndrome, except in any of the following circumstances:
(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; or
(3) as part of a preoperative evaluation.
Laboratory tests may be ordered at any time the health care
provider suspects any of these conditions, but the health care provider must
justify the need for the tests ordered with clear documentation of the
indications.
C.
Medical imaging evaluation of the lumbosacral spine must be based on the
findings of the history and physical examination and cannot be ordered before
the health care provider's clinical evaluation of the patient. Medical imaging
may not be performed as a routine procedure and must comply with all of the
standards in part
5221.6100, subparts
1 and
2. The health care provider
must document the appropriate indications for any medical imaging studies
obtained.
D. EMG and nerve
conduction studies are always inappropriate for regional low back pain as
defined in item A, subitem (1). EMG and nerve conduction studies may be an
appropriate diagnostic tool for radicular pain and cauda equina syndrome as
defined in item A, subitems (2) to (4), after the first three weeks of
radicular symptoms. Repeat EMG and nerve conduction studies for radicular pain
and cauda equina syndrome are not indicated 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.
E. The use of the
following procedures or tests is not indicated for the diagnosis of any of the
clinical categories in item A:
(1) surface
electromyography or surface paraspinal electromyography;
(2) thermography;
(3) plethysmography;
(4) electronic X-ray analysis of plain
radiographs;
(5) diagnostic
ultrasound of the lumbar spine; or
(6) somatosensory evoked potentials (SSEP)
and motor evoked potentials (MEP).
F. Computerized range of motion or strength
measuring tests are not indicated during the period of initial nonsurgical
management, but may be indicated 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 must be done in conjunction with and shall not be reimbursed separately
from an office visit with a physician, chiropractic evaluation or treatment, or
physical or occupational therapy evaluation or treatment.
G. Personality or psychosocial evaluations
may be indicated for evaluating patients who continue to have problems despite
appropriate care. The 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 which may interfere
with recovery from the injury. Since more than one of these psychological
conditions may be present in a given case, the health care provider performing
the evaluation must 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, which is interfering with recovery?
(3) Are there other personality factors or
disorders which 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?
H. Diagnostic analgesic blocks or
injection studies include facet joint injection, facet nerve injection,
epidural differential spinal block, nerve block, and nerve root block.
(1) These procedures are used to localize the
source of pain before surgery and to diagnose conditions which fail to respond
to initial nonsurgical management.
(2) These injections are invasive and when
done as diagnostic procedures only, are not indicated unless noninvasive
procedures have failed to establish the diagnosis.
(3) Selection of patients, choice of
procedure, and localization of the level of injection should be determined by
documented clinical findings indicating possible pathologic conditions and the
source of pain symptoms.
(4) These
blocks and injections can also be used as therapeutic modalities and as such
are subject to the parameters of subpart
5.
I. A comprehensive functional capacity
assessment or evaluation (FCE) is an individualized examination and evaluation
that objectively measures the patient's current level of function and the
ability to perform functional or work-related tasks, and it predicts the
potential to sustain these tasks over a defined time frame. The components of a
comprehensive FCE include, but are not limited to, neuromusculoskeletal
screening, tests of manual material handling, assessment of functional
mobility, and measurement of postural tolerance.
(1) A comprehensive FCE is not indicated
during the period of initial nonsurgical management.
(2) After the period of initial nonsurgical
management, a comprehensive FCE is indicated in either of the following
circumstances:
(a) permanent activity
restrictions and capabilities must be identified; or
(b) there is a question about the patient's
ability to do a specific job.
(3) A comprehensive FCE is not indicated to
establish baseline performance before treatment or to evaluate change in
performance during a course of treatment.
(4) Only one completed comprehensive FCE is
indicated per injury.
(5)
Functional tests or physical performance tests done as part of a work
conditioning program or work hardening program as provided in part
5221.6600, subpart
2, item D, or in conjunction
with active treatment modalities as provided in subpart
4, are not a comprehensive
FCE and are not limited by this item.
J. Consultations with other health care
providers can be initiated at any time by the treating health care provider
consistent with accepted medical practice.
Subp. 2.
General treatment parameters
for low back pain.
A. All medical care
for low back pain, appropriately assigned to a clinical category in subpart
1, item A, is determined by
the clinical category to which the patient has been assigned. General
parameters for treatment modalities are set forth in subparts
3 to
10. Specific treatment
parameters for each clinical category are set forth in subparts
11 to
13, as follows:
(1) subpart
11 governs regional low back
pain;
(2) subpart
12 governs radicular pain
with no or static neurologic deficits; and
(3) subpart
13 governs cauda equina
syndrome and radicular pain with progressive neurologic deficits.
The health care provider must, 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 must be appropriately modified to reflect the new clinical
category. However, a change of clinical category does not in itself allow the
health care provider to continue a therapy or treatment modality past the
maximum duration specified in subparts
3 to
10, or to repeat a therapy
or treatment previously provided for the same injury.
B. In general, a course of
treatment is divided into three phases.
(1)
First, all patients with low back problems, except patients with progressive
neurologic deficit or cauda equina syndrome under subpart
1, item A, subitems (3) and
(4), must be given initial nonsurgical management which may include active
treatment modalities, passive treatment modalities, injections, durable medical
equipment, and medications. These modalities and parameters are described in
subparts
3,
4,
5,
8, and
10. The period of initial
nonsurgical treatment begins with the first active, passive, medication,
durable medical equipment, or injection modality initiated. Initial nonsurgical
treatment must result in progressive improvement as specified in subpart
9.
(2) Second, for patients with persistent
symptoms, initial nonsurgical management is followed by a period of surgical
evaluation. This evaluation should be completed in a timely manner. Surgery, if
indicated, should be performed as expeditiously as possible consistent with
sound medical practice and subparts
6 and
11 to
13, and part
5221.6500. The treating health
care provider may do the evaluation, if it is within the provider's scope of
practice, or may refer the employee to a consultant.
(a) Patients with radicular pain with
progressive neurological deficit, or cauda equina syndrome may require
immediate surgical therapy.
(b) Any
patient who has had surgery may require postoperative therapy in a clinical
setting with active and passive treatment modalities. This therapy may be in
addition to any received during the period of initial nonsurgical
care.
(c) Surgery must follow the
parameters in subparts
6 and
11 to
13, and part
5221.6500.
(d) A decision against surgery at this time
does not preclude a decision for surgery made at a later date.
(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 indicated. Chronic management modalities are described in part
5221.6600, and may include durable
medical equipment as described in subpart
8.
C. A treating health care provider may refer
the employee for a consultation at any time during the course of treatment
consistent with accepted medical practice.
Subp. 3.
Passive treatment
modalities.
A. Except as set forth in
item B or part
5221.6050, subpart
8, the use of passive
treatment modalities in a clinical setting as set forth in items C to I is not
indicated beyond 12 calendar weeks after any of the passive modalities in item
C to I are initiated. There are no limitations on the use of passive treatment
modalities by the employee at home.
B.
(1) An
additional 12 visits for the use of passive treatment modalities over an
additional 12 months may be provided if all of the following apply:
(a) the employee is released to work or is
permanently totally disabled and the additional passive treatment must result
in progressive improvement in, or maintenance of, functional status achieved
during the initial 12 weeks of passive care;
(b) the treatment must not be given on a
regularly scheduled basis;
(c) the
health care provider must document in the medical record a plan to encourage
the employee's independence and decreased reliance on health care
providers;
(d) management of the
employee's condition must include active treatment modalities during this
period;
(e) the additional 12
visits for passive treatment must not delay the required surgical or chronic
pain evaluation required by this chapter; and
(f) passive care is inappropriate while the
employee has chronic pain syndrome.
(2) Except as otherwise provided in part
5221.6050, subpart
8, treatment may continue
beyond the additional 12 visits only after prior approval by the insurer,
commissioner, or compensation judge based on documentation in the medical
record of the effectiveness of further passive treatment in maintaining
employability; if the employee is permanently totally disabled, or if upon
retirement the employee is eligible for ongoing medical benefits for the work
injury, treatment may continue beyond the additional 12 visits only after prior
approval by the insurer, commissioner, or compensation judge based on
documentation in the medical record of the effectiveness of further passive
treatment in maintaining functional status.
C. Adjustment or manipulation of joints
includes chiropractic and osteopathic adjustments or manipulations:
(1) time for treatment response, three to
five treatments;
(2) maximum
treatment frequency, up to five times per week for the first one to two weeks
decreasing in frequency thereafter; and
(3) maximum treatment duration, 12
weeks.
D. Thermal
treatment includes all superficial and deep heating 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.
(1) Treatment given in a clinical
setting:
(a) time for treatment response, two
to four treatments;
(b) maximum
treatment frequency, up to five times per week for the first one to three weeks
decreasing in frequency thereafter; and
(c) maximum treatment duration, 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 which can be applied by
the patient without health care provider assistance. Home use of thermal
modalities does not require any special training or monitoring, other than that
usually provided by the health care provider during an office visit.
E. Electrical muscle stimulation
includes muscle stimulation, low-volt therapy, sine wave therapy, stimulation
of peripheral nerve, galvanic stimulation, TENS, interferential, and
microcurrent techniques.
(1) Treatment given
in a clinical setting:
(a) time for treatment
response, two to four treatments;
(b) maximum treatment frequency, up to five
times per week for the first one to three weeks decreasing in frequency
thereafter; and
(c) maximum
treatment duration, 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 must be in a supervised setting in order to
ensure proper electrode placement and patient education:
(a) time for patient education and training,
one to three sessions; and
(b)
patient may use the electrical stimulation device for one month, at which time
effectiveness of the treatment must be reevaluated by the health care provider
before continuing home use of the device.
F. Mechanical traction is the therapeutic use
of mechanically induced tension created by a pulling force to produce a
combination of distraction and gliding to relieve pain and increase
flexibility. Mechanical traction may be continuous, static, intermittent,
inversion, gravity, or positional. Examples of mechanical traction include
power traction, intersegmental motorized mobilization, vertebral axial
decompression, autotraction (active), and 90/90.
(1) Treatment given in a clinical setting:
(a) time for treatment response, three
treatments;
(b) maximum treatment
frequency, up to three times per week for the first one to three weeks
decreasing in frequency thereafter; and
(c) maximum treatment duration, 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 must be in a supervised setting in order to ensure proper
patient education:
(a) time for patient
education and training, one session; and
(b) patient may use the mechanical traction
device for one month, at which time effectiveness of the treatment must be
reevaluated by the health care provider before continuing home use of the
device.
G.
Acupuncture treatments:
(1) time for
treatment response, three to five sessions;
(2) maximum treatment frequency, up to three
times per week for one to three weeks decreasing in frequency thereafter;
and
(3) maximum treatment duration,
12 weeks.
H. Manual
therapy includes manual traction, myofascial release, joint mobilization and
manipulation, manual lymphatic drainage, soft-tissue mobilization and
manipulation, trigger point therapy, acupressure, muscle stimulation - manual
(nonelectrical), and any form of massage:
(1)
time for treatment response, three to five treatments;
(2) maximum treatment frequency, up to five
times per week for the first one to two weeks decreasing in frequency
thereafter; and
(3) maximum
treatment duration, 12 weeks.
I. Phoresis includes iontophoresis and
phonophoresis:
(1) time for treatment
response, three to five sessions;
(2) maximum treatment frequency, up to three
times per week for the first one to three weeks decreasing in frequency
thereafter; and
(3) maximum
treatment is nine sessions of either iontophoresis or phonophoresis, or
combination, to any one site, with a maximum duration of 12 weeks for all
treatment.
J. Bedrest.
Prolonged restriction of activity and immobilization are detrimental to a
patient's recovery. Bedrest should not be prescribed for more than seven
days.
K. Spinal braces and other
movement-restricting appliances. Bracing required for longer than two weeks
must be accompanied by active muscle strengthening exercise to avoid
deconditioning and prolonged disability:
(1)
time for treatment response, three days;
(2) treatment frequency, limited to
intermittent use during times of increased physical stress or prophylactic use
at work; and
(3) maximum continuous
duration, three weeks unless patient is status postfusion.
Subp. 4.
Active treatment
modalities.
Active treatment modalities must be used as set forth in items
A to D. Use of active treatment modalities can extend past the 12-week
limitation on passive treatment modalities so long as the maximum duration for
the active modality is not exceeded.
A. Education must 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 three visits,
which includes an initial education and training session, and two follow-up
visits.
B. Posture and work method
training must instruct the patient in the proper performance of job activities.
Topics include proper positioning of the trunk, neck, and arms, use of optimum
biomechanics in performing job tasks, and appropriate pacing of activities.
Methods include didactic sessions, demonstrations, exercises, and simulated
work tasks. The maximum number of treatments is three visits.
C. Worksite analysis and modification must
examine the patient's work station, tools, and job duties. Recommendations are
made 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 three visits.
D. Exercise, which is important to the
success of an initial nonsurgical treatment program and a return to normal
activity, must include active patient participation in activities designed to
increase flexibility, strength, endurance, or muscle relaxation. Exercise must,
at least in part, be specifically aimed at the musculature of the lumbosacral
spine. While aerobic exercise and extremity strengthening may be performed as
adjunctive treatment, this shall not be the primary focus of the exercise
program.
Exercises must be evaluated to determine if the desired goals
are being attained. Strength, flexibility, and endurance must be objectively
measured. While the provider may objectively measure the treatment response as
often as necessary for optimal care, after the initial evaluation the health
care provider may not bill for the tests sooner than two weeks after the
initial evaluation and monthly thereafter.
Subitems (1) and (2) govern supervised and unsupervised
exercise, except for computerized exercise programs and health clubs, which are
governed by part
5221.6600.
(1) Supervised exercise. One goal of an
exercise program must be to teach the patient how to maintain and maximize any
gains experienced from exercise. Self-management of the condition must be
promoted:
(a) maximum treatment frequency,
three times per week for three weeks, and should decrease in frequency
thereafter; and
(b) maximum
duration, 12 weeks.
(2)
Unsupervised exercise must 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:
(a)
maximum treatment frequency, up to three visits for instruction and monitoring;
and
(b) there is no limit on the
duration or frequency of exercise at home.
Subp. 5.
Therapeutic
injections.
Injection modalities are indicated as set forth in items A to
C. Use of injections can extend past the 12-week limit on passive treatment
modalities so long as the maximum treatment for injections is not
exceeded.
A. Therapeutic injections,
including injections of trigger points, facet joints, facet nerves, sacroiliac
joints, sympathetic nerves, epidurals, nerve roots, and peripheral nerves.
Therapeutic injections can only be given in conjunction with active treatment
modalities directed to the same anatomical site.
(1) Trigger point injections:
(a) time for treatment response, within 30
minutes;
(b) maximum treatment
frequency, once per week to any one site if 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 should be redirected to other areas or
discontinued. No more than three injections to different sites are reimbursable
per patient visit; and
(c) maximum
treatment, four injections to any one site.
(2) Sacroiliac joint injections:
(a) time for treatment response, within one
week;
(b) maximum treatment
frequency, can repeat injection two weeks after the previous injection if a
positive response to the first injection. Only two injections are reimbursable
per patient visit; and
(c) maximum
treatment, two injections to any one site.
(3) Facet joint or nerve injections:
(a) time for treatment response, within one
week;
(b) maximum treatment
frequency, once every two weeks to any one site if a positive response to the
first injection. If subsequent injections demonstrate diminishing control of
symptoms or fail to facilitate objective functional gains, then injections
should be discontinued. No more than three injections to different sites are
reimbursable per patient visit; and
(c) maximum treatment, three injections to
any one site.
(4) Nerve
root blocks:
(a) time for treatment response,
within one week;
(b) maximum
treatment frequency, can repeat injection two weeks after the previous
injection if a positive response to the first injection. Only three injections
to different sites are reimbursable per patient visit; and
(c) maximum treatment, two injections to any
one site.
(5) Epidural
injections:
(a) time for treatment response,
within one week;
(b) maximum
treatment frequency, once every two weeks if a positive response to the first
injection. If subsequent injections demonstrate diminishing control of symptoms
or fail to facilitate objective functional gains, then injections should be
discontinued. Only one injection is reimbursable per patient visit;
and
(c) maximum treatment, three
injections.
B. Permanent lytic or sclerosing injections,
including radio frequency denervation of the facet joints. These injections can
only be given in conjunction with active treatment modalities directed to the
same anatomical site:
(1) time for treatment
response, within one week;
(2)
maximum treatment frequency, may repeat once for any site; and
(3) maximum duration, two injections to any
one site.
C.
Prolotherapy and botulinum toxin injections are not indicated in the treatment
of low back problems and are not reimbursable.
Subp. 6.
Surgery, including
decompression procedures and arthrodesis.
Surgery may only be performed if it also meets the specific
parameters specified in subparts
11 to
13 and part
5221.6500. The health care
provider must provide prior notification of nonemergency inpatient surgery
according to part
5221.6050, subpart
9.
A. 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 lumbar
decompression or implantation of a spinal cord stimulator or intrathecal drug
delivery system; or
(2) 12 weeks
following arthrodesis.
B. Repeat surgery must also meet the
parameters of subparts
11 to
13 and part
5221.6500, and is not indicated
unless the need for the repeat surgery is confirmed by a second opinion
obtained before surgery, if a second opinion is requested by the
insurer.
C. Spinal cord stimulators
have very limited application and are indicated only if the conditions of
subitems (1), (2), and (3) are satisfied.
(1)
The treating health care provider determines that a trial screening period of a
spinal cord stimulator is indicated because the patient:
(a) has intractable pain;
(b) is not a candidate for another surgical
therapy; and
(c) has no untreatable
major psychological or psychiatric comorbidity that would prevent the patient
from benefiting from this treatment. The treating health care provider shall
refer the patient for a consultation by a psychologist or psychiatrist to
assess the patient for psychological or psychiatric comorbidities. If an
untreated comorbidity is diagnosed, reassessment for treatment with a spinal
cord stimulator is indicated if the psychologist or psychiatrist determines
that the comorbidity no longer prevents the patient from benefitting from the
treatment.
(2) Before
the trial screening is conducted, a second opinion, from a provider outside of
the treating provider's practice, must confirm that all the conditions of
subitem (1) are satisfied and the patient has no contraindications to a spinal
cord stimulator.
(3) Long-term use
of a spinal cord stimulator is indicated if the treating health care provider
documents that there has been at least a 50 percent improvement in pain during
a trial screening period of at least three days, compared to the patient's pain
level immediately preceding the trial screening period.
D. Intrathecal drug delivery systems have
very limited application and are indicated only if the conditions of subitems
(1), (2), and (3) are satisfied.
(1) The
treating health care provider determines that a trial screening period of
intrathecal drug delivery systems is indicated because the patient:
(a) has intractable pain;
(b) is not a candidate for another surgical
therapy; and
(c) has no untreatable
major psychological or psychiatric comorbidity that would prevent the patient
from benefiting from this treatment. The treating health care provider shall
refer the patient for a consultation by a psychologist or psychiatrist to
assess the patient for psychological or psychiatric comorbidities. If an
untreated comorbidity is diagnosed, reassessment for treatment with an
intrathecal drug delivery system is indicated if the psychologist or
psychiatrist determines that the comorbidity no longer prevents the patient
from benefitting from the treatment.
(2) Before the trial screening is conducted,
a second opinion, from a provider outside of the treating provider's practice,
must confirm that all the conditions of subitem (1) are satisfied and the
patient has no contraindications to an intrathecal drug delivery
system.
(3) Long-term use of an
intrathecal drug delivery system is indicated if the treating health care
provider documents that there has been at least a 50 percent improvement in
pain during a trial screening period of at least 24 hours, compared to the
patient's pain level immediately preceding the trial screening
period.
Subp. 8.
Durable medical
equipment.
Durable medical equipment is indicated only in the situations
specified in items A to D. The health care provider must provide prior
notification as required in items B and C according to part
5221.6050, subpart
9.
A. Lumbar braces, corsets, or supports are
indicated as specified in subpart
3, item K.
B. For patients using electrical stimulation
or mechanical traction devices at home, the device and any required supplies
are indicated within the parameters of subpart
3, items E and F. Prior
notification must be provided to the insurer for purchase of the device or for
use longer than one month. The insurer may provide equipment if it is
comparable to that prescribed by the health care provider.
C. Exercise equipment for home use, including
bicycles, treadmills, and stairclimbers, are indicated only within the context
of a program or plan of an approved chronic management program. This equipment
is not indicated during initial nonsurgical care or during reevaluation and
surgical therapy. Prior notification must be provided to the insurer for the
purchase of home exercise equipment. The insurer may decide which brand of a
prescribed type of exercise equipment is provided to the patient. If the
employer has an appropriate exercise facility on its premises with the
prescribed equipment, the insurer may mandate use of that facility instead of
authorizing purchase of the equipment for home use.
(1) Indications: the patient is deconditioned
and requires reconditioning which can be accomplished only with the use of the
prescribed exercise equipment. The health care provider must document specific
reasons why the exercise equipment is necessary and cannot be replaced with
other activities.
(2) Requirements:
the use of the equipment must have specific goals and there must be a specific
set of prescribed activities.
D. The following durable medical equipment is
not indicated for home use for any of the low back conditions described in
subpart
1, item A:
(1) whirlpools, Jacuzzis, hot tubs, and
special bath or shower attachments; or
(2) beds, waterbeds, mattresses, chairs,
recliners, and loungers.
Subp. 9.
Evaluation of treatment by
health care provider.
The health care provider must evaluate at each visit whether
the treatment is medically necessary, and must evaluate whether initial
nonsurgical treatment is effective according to items A to C. No later than the
time for treatment response established for the specific modality as specified
in subparts
3,
4, and
5, the health care provider
must evaluate whether the passive, active, injection, or medication treatment
modality is resulting in progressive improvement as specified in items A to
C:
A. the employee'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;
B. 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 the injury; and
C. the employee's functional status,
especially vocational activity, is progressively improving, as evidenced by
documentation in the medical record, or successive reports of work ability, of
less restrictive imitations on activity.
If there is not progressive improvement in at least two items
of items A to C, the modality must be discontinued or significantly modified,
or the provider must reconsider the diagnosis. The evaluation of the
effectiveness of the treatment modality can be delegated to an allied health
professional directly providing the treatment, but remains the ultimate
responsibility of the treating health care provider.
Subp. 11.
Specific treatment parameters for regional low back pain.
A. Initial nonsurgical treatment must be the
first phase of treatment for all patients with regional low back pain under
subpart
1, item A, subitem (1).
(1) The passive, active, injection, durable
medical equipment, and medication treatment modalities and procedures in
subparts
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 indicated
for patients with regional back pain are trigger point injections, facet joint
injections, facet nerve injections, sacroiliac joint injections, and epidural
blocks, and their use must meet the parameters of subpart
5.
(3) After the first week of treatment,
initial nonsurgical treatment must at all times contain active treatment
modalities according to the parameters of subpart
4.
(4) Initial nonsurgical treatment must be
provided in the least intensive setting consistent with quality health care
practices.
(5) Except as otherwise
specified in subpart
3, passive treatment
modalities in a clinic setting or requiring attendance by a health care
provider are not indicated beyond 12 weeks after any passive modality other
than bedrest or bracing is first initiated.
B. Surgical evaluation or chronic management
is indicated 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 indicated 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 indicated.
(1) Surgical evaluation, if indicated, may
begin as soon as eight weeks after, but must begin no later than 12 weeks
after, beginning initial nonsurgical management. An initial recommendation or
decision against surgery does not preclude surgery at a later date.
(2) Surgical evaluation may include the use
of appropriate medical imaging techniques. The imaging technique must be chosen
on the basis of the suspected etiology of the patient's condition but the
health care provider must follow the parameters of part
5221.6100. Medical imaging studies
which do not meet these parameters are not indicated.
(3) Surgical evaluation may also include
diagnostic blocks and injections. These blocks and injections are only
indicated if their use is consistent with the parameters of subpart
1, item H.
(4) Surgical evaluation may also include
personality or psychosocial evaluation, consistent with the parameters of
subpart
1, item G.
(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.
(6) The only surgical procedures indicated
for patients with regional low back pain only are decompression of a lumbar
nerve root or lumbar arthrodesis, with or without instrumentation, which must
meet the parameters of subpart
6 and part
5221.6500, subpart
2, items A and C. For
patients with failed back surgery, dorsal column stimulators or morphine pumps
may be indicated; their use must meet the parameters of subpart
6, item C.
(a) If surgery is indicated, it should be
offered to the patient as soon as possible. If the patient agrees to the
proposed surgery, it should be performed as expeditiously as possible
consistent with sound medical practice, and consistent with any requirements of
part
5221.6050, subpart
9, for prior notification of
the insurer or second opinions.
(b)
If surgery is not indicated, or if the patient does not wish to proceed with
surgery, then the patient is a candidate for chronic management according to
the parameters of part
5221.6600.
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 which
must be provided according to the parameters of part
5221.6600.
Subp. 12.
Specific treatment parameters
for radicular pain, with or without regional low back pain, with no or static
neurologic deficits.
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
subpart
1, item A, subitem (2), and
must be the first phase of treatment. It must be provided within the parameters
of subpart
11, item A, with the
following modifications: epidural blocks, and nerve root and peripheral nerve
blocks are the only therapeutic injections indicated 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 indicated.
B. Surgical evaluation or chronic management
is indicated 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 must be provided within the parameters of subpart
11, item B.
C. If the patient continues with symptoms and
objective physical findings after surgical therapy has been rendered, 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
back pain, with static neurologic deficits must meet all of the parameters of
part
5221.6600.
Subp. 13.
Specific treatment parameters
for cauda equina syndrome and for radicular pain, with or without regional low
back pain, with progressive neurologic deficits.
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 the 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 indicated, may be performed at any time during the
course of treatment. Surgical evaluation and surgery shall be provided within
the parameters of subpart
11, item B, except that
surgical evaluation and surgical therapy may begin at any time.
B. If the health care provider decides to
proceed with a course of initial nonsurgical care for a patient with radicular
pain with progressive neurologic changes, it must follow the parameters of
subpart
12, item 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 radicular pain, with or without regional
back pain, with foot drop or progressive neurologic changes at first
presentation must meet the parameters of part
5221.6600.