Health Care Provider Advisory Committee
Meeting Minutes
Aurora Medical Center in Summit
August 11, 2017

Members present: Members Present: Mary Jo Capodice, DO; BJ Dernbach (chair); Ted Gertel, MD; Richard Goldberg, MD; Maja Jurisic, MD; Jeff Lyne, DC; Michael M. McNett, MD; James O'Malley (acting chair); Jim Nelson; Jennifer Seidl, PT; and Ron Stark, MD.

Excused:  Amanda Gilliland; Barb Janusiak, RN; Scott Hardin, MD; Stephen Klos, MD; and Peter Schubbe, DC.

Staff Present:  Kelly McCormick

Observers: None

  1. Call to Order/ Introductions: Mr. O'Malley convened the Health Care Provider Advisory Committee (HCPAC) meeting at approximately 10:15 a.m., in accordance with Wisconsin's open meetings law. Dr. Ron Stark announced his retirement from medical practice effective September 1, 2017. This was the last meeting he will attend as a member of the HCPAC. The Department and the HCPAC members thanked him for his service on the committee and wished him good luck in his retirement.
  2. Acceptance of the May 5, 2017 meeting minutes: Ms. Seidl moved to approve the minutes of the January 20, 2017 meeting. Dr. Stark seconded the motion. The minutes were unanimously approved without correction.
  3. Correspondence: Ms. McCormick summarized an e-mail exchange with Dr. Kelly Worth of the Milwaukee Spine and Joint Center. Dr. Worth suggested that the CPT codes referenced in the guidelines in ch. DWD 81 needed to be updated to the CPT-10 version. He also requested that the chapter include more guidelines for treatment to the lower extremities. Dr. Worth's final concern related to the difficulty he has encountered with certain insurance carriers improperly using the treatment guidelines for purposes of utilization and review to deny treatment and reduce payments.

    A discussion took place about the scope and limitations of the treatment guidelines. The guidelines are intended for the narrow purpose of providing reference for experts to use when resolving Necessity of Treatment disputes filed with the Department under s. 102.16 (2m), Wis. Stats. Dr. Stark stated that to be used for utilization and review purposes, experts in each specialty area would need to review the guidelines approximately every 3 years to keep up with treatment trends. This would be quite costly and burdensome. Dr. Jurisic suggested adding clarification in the section on the scope to clarify if the guidelines do not address treatment for a particular area of the body, the absence should not be interpreted as meaning that the specific treatment is not covered. The HCPAC members agreed to create a letter that providers, such as Dr. Worth, could share with insurance carriers summarizing the limited scope of the guidelines and clarifying that they should not be used for utilization and review purposes.
  4. Future meeting dates: The HCPAC members agreed they will meet on October 13, 2017 and January 19, 2018. January 26, 2018 was set as a back-up meeting date in the event of inclement weather on January 19, 2018. A tentative meeting date of May 4, 2018 was also scheduled.
  5. Review of ch. DWD 81 of the Wisconsin Administrative Code: The HCPAC continued its review of the worker's compensation treatment guidelines in ch. DWD 81 of the Wisconsin Administrative Code. The following changes were proposed:

    a. Sections 81.06 (5) (b) 3. and 81.07 (5) (b) 2. Add the following language: All of the following guidelines apply to facet joint injections or facet nerve blocks (medial branch blocks):

    b. Sections 81.06 (5) (b) 4. and 81.07 (5) (b) 3. Add the following language: All of the following guidelines apply to nerve root blocks, sympathetic nerve blocks, and peripheral nerve blocks:

    c. Section 81.07 (5) (b) 3. c. Update as follows: c. Maximum treatment is 26 blocks to any one site.

    d. Section 81.07 (5) (c). Revise as follows:
    (c) For purposes of this paragraph, "lytic or sclerosing injections" include radio frequency denervation (ablation) of the facet joints. A diagnostic block resulting in a satisfactory response should precede the injection or ablation. 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: (Note: This language was also updated s. 81.06 (5 )(c) (intro).)

    1. Time for treatment response is within one week.

    2. Maximum treatment frequency, may repeat once for any site.

    23. Maximum treatment duration is 2 injections or ablations to any one site. (Note:This language was also updated in s. 81.06 (5) c. 3.)

    e. Section 81.07 (5) (d) is deleted.
    (d) Prolotherapy and botulinum toxin injections are not necessary in the treatment of neck problems.

    f. Section 81.07 (8) (c) should be updated as follows: (c) For patients using electrical muscle stimulation at home, the device and any required supplies are necessary within the guidelines of sub. (3) (e).

    g. Section 81.07 (9) (e) should be updated as follows:
    (e) If there is not progressive improvement in at least 2 categories specified in pars. (b) to (d), in par. (c) or (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.

    h. Section 81.07 (10) (a) should be updated as follows:
    (a) Prescription of controlled substance medications scheduled under ch. 450, Stats., including opioids and narcotics, are indicated primarily may be indicated for the treatment of severe acute pain. These medications are not recommended in the treatment of patients with persistent regional neck pain. (Note: This change was also made in s. 81.06 (10) (a).)

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

    (bc) A health care provider shall document the rationale for the use of any scheduled medication. Treatment with nonnarcotic medication may be is 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. (Updated s. 81.06(10) (b) and (c).)

    i. Section 81.09 (1) (b) should be updated as follows:
    (1) (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 at each visit assign the patient to the appropriate clinical category according to subds. 1. to 65. A health care provider shall document the diagnosis in the medical record. Patients may have multiple disorders requiring assignment to more than one clinical category. This section does not apply to upper extremity conditions due to a visceral, vascular, infectious, immunological, metabolic, endocrine, systemic neurologic, or neoplastic disease process, fractures, lacerations, amputations, or sprains or strains with complete tissue disruption.

    1. 'Epicondylitis.' This clinical category includes medial epicondylitis and lateral epicondylitis, including ICD-9-CM codes 726.31 and 726.32.

    21. 'Tendonitis or tendinopathy of the elbow, forearm, wrist, and hand.' This clinical category encompasses any inflammation, pain, tenderness, or dysfunction or irritation of a tendon, tendon sheath, tendon insertion, or musculotendinous junction in the upper extremity at or distal to the elbow due to mechanical injury or irritation, including, but not limited to, the diagnoses of medial and lateral epicondylitis, tendonitis, tenosynovitis, tendovaginitis, peritendinitis, extensor tendinitis, de Quervain's syndrome, intersection syndrome, flexor tendinitis, and trigger digit, including ICD-9-CM codes 726.4, 726.5, 726.8, 726.9, 726.90, 727, 727.0, 727.00, 727.03, 727.04, 727.05, and 727.2.

    32. 'Nerve entrapment syndromes.' This clinical category encompasses any compression or entrapment of the radial, ulnar or median nerves, or any of their branches, including, but not limited to, carpal tunnel syndrome, pronator syndrome, anterior interosseous syndrome, cubital tunnel syndrome, Guyon's canal syndrome, radial tunnel syndrome, posterior interosseous syndrome, and Wartenburg's syndrome, including ICD-9-CM codes 354, 354.0, 354.1, 354.2, 354.3, 354.8, and 354.9.

    43. 'Muscle Musculoskeletal pain syndromes.' This clinical category encompasses any painful condition of any of the muscles of the upper extremity, including the muscles responsible for movement of the shoulder and scapula, characterized by pain and stiffness, including, but not limited to, the diagnoses of chronic nontraumatic muscle strain, repetitive strain injury, cervicobrachial syndrome, tension neck syndrome, overuse syndrome, myofascial pain syndrome, myofasciitis, and nonspecific myalgia, fibrositis, fibromyalgia, and fibromyositis, including ICD-9-CM codes 723.3, 729.0, 729.1, 729.5, 840, 840.3, 840.5, 840.6, 840.8, 840.9, 841, 841.8, 841.9, and 842.

    54. 'Shoulder pain impingement syndromes, including shoulder impingement, tendonitis, tendinosis, bursitis, adhesive capsulitis, and related conditions.' This clinical category encompasses any inflammation, pain, tenderness, dysfunction, or irritation of a tendon, tendon insertion, tendon sheath, musculotendinous junction, or bursa in the shoulder due to mechanical injury or irritation, including, but not limited to, the diagnoses of impingement syndrome, supraspinatus tendonitis, infraspinatus tendonitis, calcific tendonitis, bicipital tendonitis, subacromial bursitis, subcoracoid bursitis, subdeltoid bursitis, and rotator cuff tendinitis, including ICD-9-CM codes 726.1 to 726.2, 726.9, 726.90, 727 to 727.01, 727.2, 727.3, 840, 840.4, 840.6, 840.8, and 840.9.

    65. 'Traumatic sprains or strains of the upper extremity.' This clinical category encompasses an instantaneous or acute injury that occurred as a result of a single precipitating event to the ligaments or the muscles of the upper extremity including ICD-9-CM codes 840 to 842.19. Injuries to muscles as a result of repetitive use, or occurring gradually over time without a single precipitating trauma, are considered muscle musculoskeletal pain syndromes under subd. 34. Injuries with complete tissue disruption are not subject to this section.

    j. Section 81.09 (1) (e) should be updated as follows:
    (e) Electromyography and nerve conduction studies are only necessary for nerve entrapment disorders, and and recurrent nerve entrapment after surgery, and any upper extremity disorder that requires additional diagnostic evaluation.

    k. Section 81.09 (1) (h) should be replaced as follows:
    (h) During the period of initial nonsurgical management, computerized range of motion or strength testing may be performed but shall be done in conjunction with an office visit with a health care provider's evaluation or treatment, or physical or occupational therapy evaluation or treatment. A health care provider may order computerized range of motion or strength measuring test during a period of chronic management when used in conjunction with a computerized exercise program, work hardening program, or work conditioning program. A health care provider may not order computerized range of motion or strength measuring tests during the period of initial nonsurgical management, but may order these tests during the period of chronic management when used in conjunction with a computerized exercise program, work hardening program, or work conditioning program. During the period of initial nonsurgical management, computerized range of motion or strength testing may be performed but shall be done in conjunction with an office visit with a health care provider's evaluation or treatment, or physical or occupational therapy evaluation or treatment.

    l. Section 81.09 (1) (i) should be updated as follows:

    (i) A health care provider may order personality or psychosocial evaluations for evaluating patients who continue to have problems despite appropriate initial nonsurgical 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, catastrophizing, fear, or anger, that is interfering with recovery?

    3. Does the patient have an elevated Adverse Childhood Experiences (ACE) score?

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

    45. Is the patient chemically dependent?

    56. Are there any interpersonal conflicts interfering with recovery?

    67. Does the patient have a pain disorder with related psychological factors?
    Does the patient have a chronic pain syndrome or psychogenic pain?

    78. In cases in which surgery is an appropriate treatment possible, are psychological factors likely to interfere with the potential benefit of the surgery?
    (Note: Sections 81.06, 81.07, 81.08, and 81.13 were also updated with this language.)

    m. Section 81.09 (1) (k) should be replaced as follows:
    (k) Functional capacity evaluation is a comprehensive and objective assessment of a patient's ability to perform work tasks. The components of a functional capacity evaluation include neuromusculoskeletal screening, tests of manual material handling, assessment of functional mobility, and measurement of postural tolerance. A functional capacity 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 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 evaluation is not typically necessary during the period of initial management.

    2. A functional capacity evaluation may be appropriate in any of the following circumstances:

    a. To delineate the patient's physical capabilities.

    b. To provide information about the patient's ability to do a specific job.

    3. A functional capacity evaluation is not the appropriate tool to establish baseline performance before treatment.

    4. A health care provider may direct only one completed functional capacity evaluation per injury unless one or more of the following exceptions exist at which time another functional capacity evaluation may be appropriate:

    a. An exacerbation of the injury occurs.

    b. A major change in the patient's health status occurs.

    c. The patient undergoes surgery that significantly changes the patient's physical status.

    d. If the initial functional capacity evaluation was for a particular job and there is a change in the job to which the patient is returning.

    e. Final determination of PPD is necessary.
    Functional capacity assessment or evaluation is a comprehensive and objective assessment of patient's ability to perform work tasks. The components of a functional capacity assessment or evaluation include neuromusculoskeletal screening, tests of manual material handling, assessment of functional mobility, and measurement of postural tolerance. A functional capacity assessment or evaluation is an individualized testing process and the component tests and measurements are determined by the patient's condition and the requested information. Functional capacity assessments and evaluations are performed to determine a patient's physical capacities in general or to determine and report work tolerance for a specific job, task, or work activity.

    1. 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.
  6. New Business: None.
  7. Adjournment: There was a motion to adjourn by Dr. McNett, seconded by Ms. Seidl. The motion passed unanimously. The meeting was adjourned at approximately 12:30 p.m. The next meeting is scheduled for October 13, 2017.