WO RKERS’ COM PENSATION TREATMEN T PARAMETER RU LES TABLE OF CONTENTS

522 1.60 10 A UT HO RIT Y. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 522 1.60 20 P UR PO SE AN D A PPLICAT ION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Subpa rt 1. Purpose. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Subp. 2. Application. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 5221.6030 INCORPORATION BY REFERENCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 5221.6040 DEFINITIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subpa rt 1. Scope. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subp. 2. Active treatm ent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subp. 3. Chronic pain syndrome. . . . . . . . . . . . . . . . . . . . . . . . . . . Subp. 4. Condition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subp. 5. Em ergen cy treatme nt. . . . . . . . . . . . . . . . . . . . . . . . . . . . Subp. 6. Etiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subp. 7. Functional status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subp. 8. Initial nonsurgical management or treatment. . . . . . . . . Subp. 9. Med ical imaging procedures. . . . . . . . . . . . . . . . . . . . . . Subp. 10. M edically neces sary treatm ent. . . . . . . . . . . . . . . . . . . Subp. 11. Neu rologic de ficit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subp. 12. Passiv e treatm ent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subp. 13. Therapeutic injection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .......... .......... .......... .......... .......... .......... .......... .......... .......... .......... .......... .......... .......... .......... . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 1 1 1 1 1 1 1 2 2 2 2 2 2 2

522 1.60 50 G EN ER AL TR EATM EN T P AR AM ET ER S; EXC ESSIVE T RE AT ME NT ; PR IOR NO TIF ICA TIO N. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Subpa rt 1. Ge neral. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Subp. 2. Documentation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Subp. 3. Non opera tive treatm ent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Subp. 4. Che mical de pend ency. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Subp. 5. Referrals between health care providers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Subp. 6. Communication between health care providers and consideration of prior care. .................................................................. 3 Subp. 7. Determinations of excessive treatment; notice of den ial to he alth ca re providers and employee; expedited processing of medical requests. . . . . . . . 4 Subp. 8. Departures from parameters. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Subp. 9. Prior notification; health care provider and insurer responsibilities. . . . . . . . . 5 Subp. 10. Certified managed care plans. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Subp. 11. Outcom e studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 522 1.61 00 P AR AM ET ER S FOR ME DIC AL IMA GIN G. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Subpa rt 1. General principles. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Subp. 2. Specific imaging procedures for low back pain. . . . . . . . . . . . . . . . . . . . . . . . . . 8 522 1.62 00 L OW BACK PAIN. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subpa rt 1. Diagnostic procedures for treatment of low back injury. . . . . . . . . . . . . . . . Subp. 2. General treatment parameters for low back pain. . . . . . . . . . . . . . . . . . . . . . . . Subp. 3. Passive treatment modalities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subp. 4. Active treatment m odalities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subp. 5. Therapeutic injections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subp. 6. Surgery, including decompression procedures and arthrodesis. . . . . . . . . . . Subp. 7. Chro nic m anag em ent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 10 12 13 15 16 17 17

Subp. Subp. Subp. Subp. Subp.

8. Durab le med ical equipm ent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 9. Evaluatio n of tre atm ent b y hea lth care prov ider. . . . . . . . . . . . . . . . . . . . . . . . . 18 10. Scheduled and nonscheduled medication. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 11. Specific treatment parameters for regional low back pain. . . . . . . . . . . . . . . 18 12. Specific treatment parameters for radicular pain, with or without regional low back p ain, w ith n o o r static neurologic deficits. . . . . . . . . . . . . . . . . . . . . . . . . . 19 Subp. 13. Specific treatment parameters for cauda equina syndrome and for radicular pain, with or without regional low back p ain, w ith p rog ress ive neu rolo gic deficits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 522 1.62 05 N EC K PAIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subpa rt 1. Diagnostic procedures for treatment of neck injury. . . . . . . . . . . . . . . . . . . . Subp. 2. General treatment parameters for neck pain. . . . . . . . . . . . . . . . . . . . . . . . . . . Subp. 3. Passive treatment modalities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subp. 4. Active treatment m odalities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subp. 5. Therapeutic injections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subp. 6. Surgery, including decompression procedures and arthrodesis. . . . . . . . . . Subp. 7. Chro nic m anag em ent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subp. 8. Durab le med ical equipm ent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subp. 9. Evaluatio n of tre atm ent b y hea lth care prov ider. . . . . . . . . . . . . . . . . . . . . . . . . Subp. 10. Scheduled and nonscheduled medication. . . . . . . . . . . . . . . . . . . . . . . . . . . . Subp. 11. Specific treatment parameters for regional neck pain. . . . . . . . . . . . . . . . . . . Subp. 12. Specific treatment parameters for radicular pain, with or without regional neck p ain, w ith n o o r static neurologic deficits. . . . . . . . . . . . . . . . . . . . . . . . . . . Subp. 13. Specific treatment parameters for radicular pain, with or without regional neck pain, with progressive neurologic changes. . . . . . . . . . . . . . . . . . . . . . . . Subp. 14. Spec ific treatment p aram eters for m yelopath y. . . . . . . . . . . . . . . . . . . . . . . . 522 1.62 10 T HO RA CIC BACK PAIN. ................................................ Subpa rt 1. Diagn ostic procedures for treatm ent of th oracic back inju ry. . . . . . . . . . . . . Subp. 2. General treatment parameters for thoracic back pain. . . . . . . . . . . . . . . . . . . Subp. 3. Passive treatment modalities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subp. 4. Active treatment m odalities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subp. 5. Therapeutic injections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subp. 6. Surgery, including decomp ression procedures. . . . . . . . . . . . . . . . . . . . . . . . . Subp. 7. Chro nic m anag em ent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subp. 8. Durab le med ical equipm ent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subp. 9. Evaluatio n of tre atm ent b y hea lth care prov ider. . . . . . . . . . . . . . . . . . . . . . . . . Subp. 10. Scheduled and nonscheduled medication. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subp. 11. Specific treatment parameters for regional thoracic back pain. . . . . . . . . . . Subp. 12. Specific treatment parameters for radicular pain. . . . . . . . . . . . . . . . . . . . . . . Subp. 13. Spec ific treatment p aram eters for m yelopath y. . . . . . . . . . . . . . . . . . . . . . . . . 522 1.63 00 U PPER EX TR EM ITY DIS OR DE RS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subpa rt 1. Diagnostic procedures for treatment of upper extrem ity disorders (UE D). .................................................................. Subp. 2. Gen eral treatmen t param eters for up per extrem ity disorders. . . . . . . . . . . . . Subp. 3. Passive treatment modalities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subp. 4. Active treatment m odalities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subp. 5. Therapeutic injections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subp. 6. Surge ry. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subp. 7. Chro nic m anag em ent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subp. 8. Durab le med ical equipm ent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subp. 9. Evaluatio n of tre atm ent b y hea lth care prov ider. . . . . . . . . . . . . . . . . . . . . . . . . 20 20 22 23 25 26 26 27 27 27 28 28 29 29 30 30 30 32 33 35 36 36 37 37 37 38 38 39 39 40 40 42 43 45 45 46 46 46 47

Subp. Subp. Subp. Subp. Subp. Subp. Subp.

10. Scheduled and nonscheduled medication. . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 11. Specific treatment parameters for epicondylitis. . . . . . . . . . . . . . . . . . . . . . . 47 12. Specific treatment parameters for tendonitis of forearm, wrist, and hand. . 48 13. Specific treatment parameters for nerve entrapment syndromes. . . . . . . . . 48 14. Sp ecific treatment param eters for muscle p ain syndromes. . . . . . . . . . . . . . 49 15. Specific treatment parameters for shoulder impingement syndromes. . . . . 49 16. Sp ecific treatment param eters for trau matic sprains and strains of the upper extrem ity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

5221.6305 REFLEX SYMPATHETIC DYSTROPHY OF THE UPPER AND LOW ER EX TR EM ITIE S. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subpa rt 1. Scope. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subp. 2. Initial nonsurg ical man agem ent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subp. 3. Surge ry. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subp. 4. Chro nic m anag em ent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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50 50 50 52 52

522 1.64 00 IN PATIE NT HO SPITA LIZA TIO N P AR AM ET ER S. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Subpa rt 1. General principles. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Subp. 2. Specific requirements for hospital admission of patients with low back pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 522 1.65 00 P AR AM ET ER S FOR SU RG ICA L PR OC ED UR ES. . . . Subpa rt 1. Ge neral. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subp. 2. Spina l surgery. . . . . . . . . . . . . . . . . . . . . . . . . . Subp. 3. Upp er extrem ity surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...... ...... ...... ...... . . . . . . . . . . . . . . . . . . . . . . . . ...... ...... ...... ...... . . . . . . . . 53 53 53 55

522 1.66 00 C HR ON IC M AN AG EM EN T. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 Subpa rt 1. Scope. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 Subp. 2. Chronic managem ent modalities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 522 1.89 00 D ISC IPLIN AR Y AC TIO N; P EN ALTIE S. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subpa rt 1. Discipline. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subp. 2. Com plaints. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subp. 3. Review and investigation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subp. 4. Cooperation with disciplinary proceedings. . . . . . . . . . . . . . . . . . . . . . . . . . . . Subp. 5. In-person meeting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subp. 6. Reso lution by instru ction or w ritten agreem ent. . . . . . . . . . . . . . . . . . . . . . . . . Subp. 7. Inappropriate, unnecessary, or excessive treatme nt. . . . . . . . . . . . . . . . . . . . Subp. 8. Violations of statutes and rules other than those involving inappropriate, unn ecessa ry, or excessive trea tmen t. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subp. 9. Penalties. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 61 61 61 61 62 62 62 62 62

5221.6010

STATE OF MINNESOTA

Treatment Parameter Rules

522 1.60 10 AU TH OR ITY . Parts 5221.6010 to 5221.8900 are adopted under the authority of Minnesota Statutes, sections 176.83, subdivisions 1, 3, 4, and 5, and 176.103, sub division 2. STAT AUTH : MS s 176.103; 176.83 HIST: 19 SR 1412 522 1.60 20 P UR PO SE AND APPLIC ATIO N. Subpa rt 1. Purpose. Parts 522 1.60 10 to 5221.6600 estab lish param ete rs for rea sonably r e q u ir e d t re a t m e n t o f e m p l o y e e s wit h com pensable workers ' com pen sation injuries to prevent exc ess ive se rvices un der M innesota Statutes, sections 176.135 and 176.136, subdivision 2. Parts 5221.6010 to 5221.6600 do not affect any determ ination of liability for an injury under Minnesota Statutes, chapter 176, and a re not intended to expand or restrict a hea lth care pro vider's scope o f practice under any o ther statute. Subp. 2. Application. All treatment must be m edically necess ary as defined in part 5221.6040, subpa rt 10. In the absence of a specific param eter, any applicable general param eters govern. A dep arture from a param eter that limits the duration or type of treatment m ay be app ropriate in any one of the circumstances specified in part 5221.60 50, subp art 8. Parts 5221.6010 to 5221.6600 apply to all treatment provided after January 4, 1995, regardless of the date of in jury. All limitations on the duration of a specific treatm ent m oda lity or type of m oda lity be gin with the first tim e the m oda lity is initiated after January 4, 1995. However, consideration may be given to treatment initiated under the emergency rules (parts 5221.6050 to 5221.6500 Emergency). Parts 5221.6010 to 5221.6600 do not apply to treatment of an injury after an insurer has denied liability for the injury. However, in such cases the rules do apply to treatment initiated after liability has been established. Re ferences to days and week s in parts 5221.6050 to 5221.6600 mean calendar days and weeks unless specified othe rwise . STAT AUTH : MS s 176.103; 176.83 HIST: 19 SR 1412 5221.6030 INCORPORATION BY REFERENCE. The ICD-9-CM diagnostic c odes referenced in parts 5221.6010 to 5221.6600 a re contained in the fourth edition of the International Classification of Diseases, Clinical Modification, 9th Revision, 1994, and corresponding annual updates . This document is subje ct to annual re visions and is incorporated by referenc e. It is published by the

United States Department of Health and Human Services, Health Care Financing Administration, and may be purchased through the Superintendent of Docum ents, United States Government Printing Office, W ashington, D.C. 20402. It is a vailable through the Minitex interlibrary loan system. STAT AUTH : MS s 176.103; 176.83 HIST: 19 SR 1412 5221.6040 DEFINITIONS. Subpa rt 1. Scope. The term s us ed in p arts 5221.6010 to 5221.6600 h ave the meanings given them in this pa rt. Subp. 2. Active treatm ent. "Active treatm ent" mea ns treatm ent spec ified in pa rts 5221.6200, subpart 4; 5221.6205, subpart 4; 5221.6210, subpart 4; 5221.6300, subpart 4; and 5221.6305, subpart 2, item C, which requires active patien t participation in a therapeutic program to incre ase flexibility, streng th, endurance, or awareness of proper body m ech anics. Subp. 3. Chronic pain syndrome. "Chronic pain syndrom e" m ean s an y set of verbal or non verb al beh aviors that: A. involve the com plaint of end uring pain; B. differ sign ificantly from the patient's preinjury behavior; C. have not responded to previous app ropriate trea tm ent; D. are not consistent with a know n organic syndrome which has remained untreated; and E. interfere with physical, psyc hological, soc ial, or voc ationa l functioning. Subp. 4. Condition. A patient's "condition" means the symptom s, physical signs, clinical findings, and fu nction al status that characterize the com plaint, illness, or injury related to a current claim for com pen sation . Subp. 5. Emergenc y treatmen t. "Emergency treatm ent" m ean s trea tm ent that is: A. required for the im m edia te diagnosis and treatment of a medical condition that, if not im m ediate ly diagnosed and treated, could lead to serious physical or m enta l disability or death; or B. im m ediate ly necessary to alleviate severe pain. Emergency treatment includes treatment delivered in response to symptoms that may or may not represent an actual emergency but that is neces sary to determine whether an emergency exists. Subp. 6. Etiology. "Etiology" means the anatom ic alteration, physiologic dysfunction, or other biological or psychological abnormality which

TP-1

5221.6040

STATE OF MINNESOTA

Treatment Parameter Rules

is considered a cause of the patien t's condition. Subp. 7. Functional status. "Functional status" means the ability of an individual to engage in activ ities of d aily livin g and other social, recreational, an d vocation al activities. Subp. 8. Initial nonsurgical management or treatm ent. "Initial nonsurgical management or treatm ent" is initial treatment provided after an injury that includes pa ssive treatme nt, active treatm ent, injections, and durable medical equipment under parts 5221.6200, subparts 3, 4, 5, and 8; 5221.6205, subparts 3, 4, 5, and 8; 5221.6210, sub parts 3, 4, 5, and 8; 5221.6300, sub parts 3, 4, 5, and 8; and 5221.6305, subpart 2. Scheduled and nonscheduled medication may be a part of initial nonsurgical treatment. Initial nonsurgical managem ent does not include surgery or chronic m anagem ent m odalities unde r part 522 1.66 00. Subp. 9. Med ical imaging procedures. A "medical imaging pro ced ure" is a technique, process, or technology used to create a visual image of the body or its function. Medical imaging includes, but is not limited to: X-rays, to m ography, angiography, venography, m yelography, com puted tomography (CT) scanning, magnetic resonance im aging (MRI) scanning, ultrasound imaging, nuclear isotope imaging, PET scanning, and the rm ography. Subp. 10. Med ically necessary treatm ent. "Medically necessary treatment" means those hea lth services for a com pensa ble injury that are reasonable and necessary for the diagnosis and cure or s ignificant relief of a condition consistent with any app licable tre atm ent param eter in p arts 5221.6050 to 5221.6 600 . W here parts 5221.6050 to 5221.6600 do not govern, the treatment m ust be reasonable and nec essary for the diagnosis or cure and significant relief of a condition consistent with the current accepted standards of practice with in the scope of the provider's license or certification. Subp. 11. Neu rologic de ficit. "Neurologic deficit" means a loss of function secondary to involvement of the central or peripheral nervous system. This m ay includ e, but is not limited to, m otor loss; spasticity; loss of reflex; radicular or anato m ic sensory loss; loss of bowel, bladder, or erectile function; impairment of special senses, including vision, hearing, tas te, o r sm ell; or deficits in cog nitive or m em ory fun ction. A. "Static neurologic deficit" means any neurologic deficit that has remained the sam e by history or noted by repeated exa m ination since on set. B. "Progressive neurologic deficit" means any neurologic deficit that has become worse by history or noted by repe ate d

exa m ination since on set. Subp. 12. Passive treatm ent. "Passive treatm ent" is any treatm ent m oda lity specified in parts 5221.6200, subpart 3; 5221.6205, subpart 3; 5221.6210, subpart 3; 5221.6300, subpart 3; and 5221.630 5, subpart 2, item B. Pas sive treatment modalities include be dres t; therm al treatm ent; t r a c ti o n ; acupun cture ; e l e c tr ic a l m u s c le stim ula tion; braces; manual and mechanical the rapy; massage; and adjustm ents . Subp. 13. Th erap eutic injection. "Therapeutic injection" is any injectio n m odality specified in parts 5221.6200, subpart 5; 5221.6205, subpart 5; 5221.6210, subpart 5; 5221.6300, subpart 5; and 5221.6305, sub part 2 , item A. Therapeutic injections include trigger point injections, sacroiliac injections, facet joint injections, facet nerve blocks, nerve root blocks, epidural injections, soft tissue injections, peripheral nerve blocks, injections for peripheral nerve entrapme nt, an d sym pathe tic blocks. STAT AUTH : MS s 176.103; 176.83 HIST: 19 SR 1412 5221.6050 GENERAL TREATMENT PARAM ETE RS; E XCE SSIVE TR EATM ENT ; PRIOR NOTIFICATION. Subpa rt 1. Ge neral. A. All treatmen t mus t be m edically necess ary treatment, as defined in part 5221.6040, subpa rt 10. The health care provider must evaluate the m edical necessity of all treatment under item B on an ongoing basis. Parts 5221.6050 to 5221.6600 do not require or perm it any more frequent examinations than would normally be required for the condition being treated, but do require ongoing evaluation of the patient that is m edically necessary, con sistent with acc epte d m edical practice. B. The health care provider must evaluate at each visit whe ther initial nonsurgical treatment for the low back , ce rvic al, thoracic, and upper extremity conditions specified in parts 5221.6200, 5221.6205, 5221.6210, and 5221.6300, is effective according to subitems (1) to (3). No later than any applicable treatment response tim e in parts 5221.6200 to 5221.6300, the hea lth care provider must evaluate whether the passive, active, injection, or medication treatm ent modality is resulting in progress ive impr ovem ent as specified in sub item s (1) to (3): (1) the em ployee 's subjec tive com plaints of pain or dis ability are progressively i m p r o v in g , a s e v id e n c e d b y

TP-2

5221.6050

STATE OF MINNESOTA

Treatment Parameter Rules

documentation in the medical record of decreased distribution, frequency, or intens ity of sym ptom s; (2) the objective clinical findings are progress ively improving, as evidenced by documentation in the medical record of resolution or objectively measured improvement in physical signs of injury; and (3) the employee's functional status, especially vocation al activities , is progress ively improving, as evidenced by documentation in the medical record, or successive reports of work ability, of le ss res trictive limitations on activity. Except as otherw ise provide d un der p arts 5221.6200, subpart 3, item B; 5221.6205 , subpart 3, item B; 5221.6210, subpart 3, item B; and 5221.6300, subpart 3, item B, if there is not progressive improvement in at least two of subitem s (1) to (3), the modality must be discontinued or s ignificantly modified, or the provider must reconsider the diagnosis. The evaluation of the effectiveness of the treatment m oda lity can be delegated to an allied health professional directly providing the treatment, but remains the ultim ate res ponsibility of the treating hea lth care pro vider w ho o rdered the trea tm ent. C. The hea lth care provider must use the least intensive setting appropriate and m ust assist the em plo yee in b ec om ing independent in the employee's own care to the extent possible so that prolonged or repeated use of health care providers and m edical facilities is m inim ized. Subp. 2. Documentation. A health care provider m ust maintain an appropriate record, as defined in part 5221.0100, subpart 1a, of any treatm ent provide d to a patien t. Subp. 3. Non opera tive treatm ent. Health care providers shall provide a trial of nonope rative treatment before offering or performing surgical treatment un less the treatment for the condition requires imm ediate surgery, unless an emergency situation exists, or unless the accepted standard of initial treatm ent fo r the c ond ition is surgery. Subp. 4. Che mical de pend ency. The hea lth care provider shall maintain diligence to detect incipient or actual chemical dependency to any medication prescribed for treatment of the em ploye e's condition. In cases of incipient or actual depend ency, the health care pro vider shall refer the employee for appropriate evaluation and treatm ent of the d epe nde ncy. Subp. 5. Re ferrals betw een health care providers. The primary health care provider directing the course of treatm ent sh all m ak e tim ely

and appropriate referrals for consultation for opinion or for the transfer of care if the primary hea lth care provider does not have any rea sonable alternative treatmen t to offer and th ere is a reasonable likelihood that the consultant may offer or recomm end a reasonable alternative treatment plan. T his sub part d oes not prohibit a referral for consultation in other circumstances based on accepted m edical pra ctic e and the patien t's con dition. A. Referrals from consulting health care provider. If the consultan t has reasonable belief that anothe r con su ltatio n is appro p r ia t e , that c ons ultant m u st coo rdinate furthe r referral with the original treating hea lth care pro vider u nless the consultant has been approved as the em ploye e's treating health care provider. The consu ltant is un der n o ob ligation to provide or recomm end treatment or further referral, if in the consulta nt's opinion, all reasonable and necessary treatment has been rend ered . The consultant shall in this situation refer the em ployee bac k to th e original treating health care provider for further follow-up. B. Information sen t to consultant. W hen a referring health care provider arranges for consultation or transfer of care, except in cases of em erge ncy, the referring health care p r o v id e r s h a ll , w i th p a tient authorization, sum m arize for the consultant orally or in writing the conditions of injury, the working diag nos is, the tre atm ent to date, the patient's resp ons e to treatm ent, all relevant laboratory and medical imaging studies, return to work considerations, and any other informa tion relevant to the consultation. In addition, the referring hea lth care pro vider shall m ak e available to the con sultan t, with patient authorization, a copy of all medical records relevant to the em ployee 's injury. Subp. 6. Communication between health care prov iders and consideration of prior care. A. Information requ este d by ne w he alth care provider. Upon accepting for treatm ent a patient with a workers' compensation inju ry, the health care provider shall ask the patient if treatment has been previously given for the injury by another health care provider. If the pa tient rep orts that treatment has been previously given for the injury by another health care provider and if the medical records for the injury have not been transferred, the new hea lth care provider shall request authorization from the employee for relevant medical records.

TP-3

5221.6050

STATE OF MINNESOTA

Treatment Parameter Rules

U p o n r e c e i p t o f th e e m p l oye e authorization, the new h ealth care provider shall request relevant m edical records from the previous hea lth care pro viders . Upon receipt of the request for medical records and em ployee authorization , the previous hea lth care providers shall provide the records within seven wo rking da ys. B. Treatment by prior health care provider. If the employee has reported that care for an injury ha s be en p reviou sly given: (1) W here a previous hea lth care provider has perform ed d iagnostic imaging, a hea lth care provider may not repeat the imaging or p erform alterna te diagnostic imaging for the same condition except as p erm itted in part 522 1.61 00. (2) W hen a therapeutic modality employed by a health care provider was no longer im pro ving the em ploye e's condition und er su bpa rt 1, item B, or has bee n us ed fo r the maxim um d u r a ti o n a l lo w e d u n d e r p a r t s 5221.6050 to 5221.6600, another hea lth care provider may not employ the same m odality at any tim e thereafter to treat the sam e injury except if one of the departures applies under subpart 8, after surgery, or for treatment of reflex s ym path etic dystrophy un der p art 52 21.6 305 . (3) It is also inap prop riate for two h ealth care providers to use the same treatm ent m oda lity concu rrently. C. Em ployee refusal. An employee's refusal to provide authorization for release of medical records do es not justify repeat treatment or diagn ostic testing . An insurer is not liable for repeat diagnostic testing or other duplicative treatment prohibited by this su bpa rt. Subp. 7. De term inations of excessive treatme nt; notice of den ial to he alth ca re providers and employee; expedited processing of medical requests. A. In addition to services deem ed exce ssive under part 5221 .050 0 an d M innesota Statutes, section 176.136, subdivision 2, treatm ent is e xce ssive if: (1) the treatment is inconsistent with an applicable param ete r or other rule in parts 5221.605 0 to 5221.6600 ; or (2) the treatm ent is consisten t with the param eters in parts 5221.6 050 to 5221.6600, but is not m edically nec ess ary treatm ent. B. If the insurer denies payment for treatment

that dep arts from a param eter u nde r parts 5221.6050 to 5221.6600, the insurer must provide the employee and health care provider with written notice of the reason for the denial and that the treatment rules perm it departure from the parameters in specified circumstances. If the insurer deni es authorizati on for proposed treatment after prior notification has been given und er su bpa rt 9, the insurer must provide the employee and health care provider in writing w ith notice of the reason why the information given by the he alth care provider does not support the proposed treatment and notice of the right to review of the den ial under su bpa rt 9, item C. The insurer may not deny payment for a program of chronic management that the insurer has previously authorized for an employee, either in writing or by routine payment for services, without providing the employee and the employee's health care provider with at least 30 days' notice of intent to apply any of the chronic m a n a g e m e n t p a ra m e t e r s i n pa r t 5221.6600 to future treatment. The notice must include the specific parameters that will be applied in future determinations of com pen sab ility by the ins urer. C. If the insurer denies authorization or payment for treatment governed b y parts 5221.6050 to 5221.6600, the hea lth care provider or the em ployee m ay reques t a determination from the comm issioner or com pensation judge by filing a medical request or petition under chapter 5220 and Minnes ota Statutes, sections 176.106, 176.2615, and 176.305. The medical request may not be filed before completion of the managed care plan's dispute resolution process, if applicable. If the hea lth care provider has notified the insurer of proposed treatment requiring prior notification under sub part 9 , the he alth care provider or employee must describe or attach a copy of the notification, and any response from the ins urer, to the medical request filed with the department. The insurer m ay, but is not required to, file a medical response where the ins ure r's response to prior notification under subpart 9 has bee n attached to the medical requ est. If the insurer elects to file a medical response in such cases, it must be received within ten working days of the date the medical request was filed with the dep artm ent. The comm issioner or compensation judge may issue a decision based on written submissions no earlier

TP-4

5221.6050

STATE OF MINNESOTA

Treatment Parameter Rules

than ten working days after receipt of the medical request, unless a medical respon se h as b een filed so one r. D. A determination of the compensability of medical treatment under Minnesota Statutes, chapter 176, must include con sideration of the following fac tors: (1) whe ther a treatment parameter or other rule in parts 5 221 .605 0 to 5221.6600 applies to the etiology or diagnos is for the co ndition; (2) if a specific or ge neral parameter applies, wheth er the treatm ent is c o n s i s te n t w i t h t h e t r ea t m e n t parameter and whe ther the treatment was medically necessary as defined in part 5221.6040, subpart 10; and (3) whether a departure from the applicable parameter is or was necessary because of any of the factors in sub part 8 . Subp. 8. Departures from parameters. A departure from a para m eter that limits the duration or type of tre atm ent in p arts 5 221 .605 0 to 5221.6600 may be appropriate in any one of the circumstances specified in items A to E. The hea lth care provider must provide prior notification of the dep arture as requ ired by subpart 9 . A. W here there is a documented medical com plication . B. W here previous treatment did not meet the accepted standard of practice and the requirements of pa rts 52 21.6 050 to 5221.6600 for the health care provider who orde red th e trea tm ent. C. W here the treatment is necessary to assist the em ployee in the initial return to work where the em ploye e's work activities place stress on the part of the body affected by the work injury. The health care provider must doc um ent in the medical record the specific work activities that place stress on the affected body part, the details of the treatment plan and treatment delivered on each visit, the employee's response to the treatm ent, and efforts to promote em ployee independence in the emp loyee's own care to the exten t poss ible so that prolonged or repeated use of health care providers and m edical facilities is m inim ized. D. W here the treatment continues to meet two of the following three criteria, as doc um ente d in the m edical record: (1) the em ployee 's subjec tive com plaints of pain are pro gressively improving as evidenced by documentation in the m e d i c a l r e c o r d o f d e c r e a s ed distribution, frequency, or intensity of sym ptom s; TP-5

(2) the employee's objective clinical findings are progressively improving, as evidenced by docum entatio n in the medical record of resolution or objec tively m easured im provem ent in physical signs of injury; and (3) the employee's functional status, es pe cia lly vocational activity, is objec tively improving as evidenced by documentation in the medical record, or suc ces sive re ports of work ability, of less restrictive limitations on activity. E. W here there is an incapacitating exacerbation of the employee's condition. How ever, add itional trea tm ent for the incapacitating exacerbation may not exceed, and must comply with, the param eters in parts 5221.6050 to 522 1.66 00. Subp. 9. Prior notification; health care provider and insu rer respon sibilities. Prior notification is the responsibility of the hea lth care provider who wants to provide the treatm ent in item A. Prior notification need not be given in any cas e wh ere e m erge ncy treatm ent is re quired. A. The health care provider must notify the insurer of proposed treatment in subitems (1) to (4) at least seven working days before the treatment is initiated, except as othe rwise provided in sub item (4): (1) for chronic m anagement m odalities where prior notification is required und er pa rt 522 1.66 00; (2) for durable medical equipment requiring prior notifica tion in pa rts 5221.6200, subpart 8; 5221.6205, subpart 8; 5221.6210, subpart 8; and 522 1.63 00, subp art 8; (3) for any nonemergency inpatient hospitalization or nonemergency inpatient surgery. A surgery or hospitalization is considered inpatient if the patient spends at least one night in the facility; and (4) for treatment that departs from a parameter limiting the duration or type of treatment in parts 5221.6 050 to 5221.6600. The he alth care provider must notify the insurer within two business days after initiation of treatment if the departure from a parameter is for an incapacitating exa cerbation or an em erge ncy. B. The health care provider's prior notification required by item A may be made orally, or in writing, and shall provide the following inform ation, w hen releva nt: (1) the diagnosis;

5221.6050

STATE OF MINNESOTA

Treatment Parameter Rules comm issioner of L abor and Industry. The insurer may also delegate the review to a certified m anaged care plan under subpart 10. In lieu of o r in addition to the insurer's review under this sub item , the insurer may request an examination of the employee under subitem (4), (5), or (6) and the requ irem ents of those subite m s apply to the prop ose d trea tm ent. Unless an examination of the em ployee is requested under subitem (4), (5), or (6), the insurer's determ ina tion f o l lo w i n g review m ust be comm unicated orally or in writing to the requestor within seven working days of receipt of the reque st for review . Instead of requesting a review, or if the insurer m aintain s its denial after the review, the health care provider or the em ployee may file with the com m issioner a m edical request or a petition for au thorization of the treatment under sub part 7, item C, or except as spec ified in subitem (4), (5), or (6), may proceed with the proposed t r e at m e n t sub j e c t to a lat e r determination of compensability by the comm issioner or compensation judge. (4) If the insurer requests an examination of the em ploye e by the e m ploye r's physician, the health care provider may elect to provide the trea tm ent subje ct to a determ ination of co m pen sab ility by the comm issioner or compensation judge under sub part 7, item B. How ever, the health care provider may not provide nonemergency surgery where the insurer has requested an examination for surgery except as provided in subitems (5) and (6), and may not provide contin ued passive care modalities where prior approval by the insurer, co m m issioner, or compensation judge is required under parts 5221.6200, subpart 3, item B, subitem (2); 5221.6205, subpart 3, item B, su bitem (2); 52 21.6 210, subpa rt 3, item B, su bitem (2); and 5221.6300, subpart 3, item B, subitem (2). (5) If prior notification of surgery is required under item A, subitem (3), the insurer may require that the employee obtain a second opinion from a physician of the employee's choice under Minnesota Statutes, section 176.135, subdivision 1a. If within seven working days of the prior

(2) when giving prior notification for ch ro nic managem ent modalities, durable m ed ical equ ipm ent, o r inpatient hospitalization or surgery required by item A, subitem s (1) to (3), whether the proposed treatm ent is c o n s i s te n t w ith th e a p pli c a b le treatm ent param eter; (3) when giving prior notification for treatment that departs from a treatment parameter, or notification of treatment for an incapacitating exacerbation or emergency, the basis for departure from any applicable treatment param ete r specified in subpa rt 8; the treatment plan, including the nature and anticipated length of the p r o p o s e d t re a t m e n t ; a n d th e anticipated effect of treatment on the em ployee 's condition. C. The insurer must provide a toll-free facs im ile and telephone number for hea lth care providers to provide prior notification. The insurer m ust respond orally or in writing to the reques ting health care pro vider's prior notification of proposed treatment in item A within seven working da ys of receipt of the request. W ithin the seven days, the insurer must either approve the request, deny authorization, request additional information, request that the em ployee obtain a second opinion, or request an examination by the employe r's physician. A denial must include notice to the employee and health care provider of the reason why the information given by the hea lth care provider in item B does not suppo rt the treatment proposed, along with notice of the right to review of the denial und er su bitem (3). (1) If the health care provider does not receive a response from the insurer with in the seven working days, authorization is deemed to have been given. (2) If the insurer authorizes the treatm ent, the insurer may not later deny payment for the treatm ent autho rized. (3) If the insurer denies authorization, the health care provider or employee may orally or in writing request that the i n s u re r r e vie w it s d e n i al o f auth orization . The insurer's review of its denial must be made by a currently licensed registered nurse, m edical doctor, doctor of osteopathy, doctor of chiropractic, or a person credentialled by a program approved by the TP-6

5221.6050

STATE OF MINNESOTA

Treatment Parameter Rules

notification the insurer notifies the employee and health care provider that a second opinion is required, the hea lth care provider m ay not perform the nonemergency surgery until the employee provides the second opinion to the insurer. Except as otherwise provided in parts 522 1.62 00, subpart 6, items B an d C; 5221.6205, subpart 6, item s B and C; 5221.6300, subpart 6, item B; and 5221.6305, subpart 3, item B, if the insurer denies authorization with in seven working days of receiving the second opinion, the health care provider may elect to perform the surgery, subject to a determination of compe nsab ility by the comm issioner or compensation judge under subpart 7. (6) In any case where prior notification of proposed surgery is required, the insurer may elect to obtain an examination of the employee by the em ploye r's physician under Minnes ota Statutes, section 176.155, sometimes referred to as an "independent medical exa m ination." If the insurer notifies the employee and health care provider of the examination within seven working days of the provider's notification, the proposed nonemergency surgery may n o t b e p ro v id e d p endin g th e exam ination. Ho we ver, after 45 days following the ins urer's reques t for an examination, the health care provider may elect to proceed with the surgery, subject to a dete rm ination of com pen sab ility by the comm issioner or com pensation judge under subpart 7. (7) The insurer's request for additional information must be directed to the requesting health care provider and must specify the additional information required that is necessary to respond to the health care pro vider's notification of prop ose d trea tm ent. The proposed treatment may not be given until the p r o v id e r p r o v id e s r e a s o n a b l e additional information. Once the additional information has been received, the insurer must respond with in seven working days according to sub item s (1) to (6). Subp. 10. Certified managed care plans. The insurer may delegate responsibility for the notices requ ired in subp art 7, item B, and the response to prior notification u nde r sub part 9 , to the certified managed care plan with which the insurer has con tracte d to m anage the em ploye e's medical treatment under Minnesota Statutes, TP-7

section 176.135, subdivision 1f. Alternatively, the managed care plan m ay act as an interme diary between the treating health care provider and the insurer. In either case, the notices and tim e periods in sub parts 7, 8, an d 9 also ap ply to the managed care pla n. W here the insurer has delegated resp ons ibility to the managed care plan, the insurer m ay not later deny treatment auth orized by the plan. Subp. 11. Outcom e studies. The comm issioner shall perform outcom e studies on the treatment modalities in parts 5 221 .620 0 to 5221.6600. The m odalities to be studied shall be selected in consultation with the Workers' Com pensation Medical Services Review Board. The com m issioner m ay require health care providers who use these moda lities to pros pe ctively gather and report outcom e information on patients treated, with necessary consent of the em ployee. The health care providers shall report the outcome information on the modalities in parts 5221.6200 to 5221.6600 on a form prescribed by the comm issioner, which may includ e: A. the nam e of the he alth ca re provide r; B. the name of the patien t, date o f injury, da te of birth, gender, and, with patient permission, level of education and social sec urity num ber; C. the name of the workers' compensation insurer and m ana ged care plan, if an y; D. the pretre atm ent and posttreatment em ploym ent status; E. the nature of treatment given before and after the treatment being studied for the sam e co ndition; F. the diagnosis, symptoms, physical findings, and functional status before and after the treatment being studied for the sam e condition; and G. the presence or absence of preexisting or con current c ond itions. STAT AUTH : MS s 176.103; 176.83 HIST: 19 SR 1412 5221.6100 PARAMETERS FOR MED ICAL IM AGING . Subpa rt 1. General principles. All medical imaging m ust c om ply with item s A to E. Except for emergency evaluation of significan t traum a, a hea lth care pro vider m ust docum ent in the medical record an appropriate history and physical examination, along with a review of any existin g medical records and laboratory or imaging studies regarding the patient's condition, before ordering any im aging study. A. Effective imaging. A health care provider

5221.6100

STATE OF MINNESOTA

Treatment Parameter Rules

B.

C.

D.

E.

should initially order the single most effective imaging study for diagnosing the suspected etiology of a patient's condition. No concurrent or ad ditional im aging stu dies should be ordered until the results of the first study are known and reviewed by the treating health care provider. If the first imaging study is negative, no additional imaging is indicated except for repeat and alternative imaging allowed under items D and E. Approp riate im aging. Im aging solely to rule out a diagnosis not seriously being considered as the etiology of the patient's con dition is not indicated . Routine imaging. Imaging on a routine ba sis is not indicate d un less the information from the study is nec ess ary to develop a treatm ent plan. Repeat im aging. R epeat imaging, of the sam e views of the sam e body part with the sam e imaging modality is not indicated exc ept as follow s: (1) to diagnose a s uspec ted fracture or sus pec ted disloca tion; (2) to monitor a therapy or treatment which is known to result in a change in imaging findings and imaging of these changes are necessary to determine the efficacy of the therapy or treatm ent; repeat imaging is not app ropriate solely to determine the efficacy of p hys ica l the rapy or chiroprac tic treatm ent; (3) to follow up a surg ical pro ced ure; (4) to diag nose a ch ange in the patient's condition marked by new or altered physical findings; (5) to evaluate a new episode of injury or exacerbation which in itself would warrant an im aging study; or (6) when the treating hea lth care provider and a radiologist from a different practice have reviewed a previous imaging study and agree that it is a tech nically inad equ ate study. Altern ative im aging. (1) Persistence of a patient's subjective complaint or failure of the con dition to respond to treatment are not legitim ate indications for repeat im aging. In th is instance an alternative imag ing study may be indicated if another etiology of the patient's condition is suspected because of the failure of the condition to im prov e. (2) Alternative imaging is no t allowed to follow up negative findings unle ss there has been a change in the TP-8

suspected etiology and the first imaging study is not an app ropriate evaluation for the suspected etiology. (3) Alternative im aging is allowe d to follow up abnorm al but inconclusive findings in another im aging study. An inconc lusive finding is one that does not provide an adequate basis for acc urate diagn osis. Subp. 2. Spe cific ima ging procedures for low back pain. Exc ept fo r the emergency evaluation of significant traum a, a health care provider m ust docum ent in the medical record an app ropriate history and physical examination, along with a review of any existing medical records and laboratory or imaging studies regarding the patient's condition, before ordering any imaging stud y of the low ba ck. A. Com puted tomo graphy (CT) scanning is indicated any time that one of the following con ditions is m et: (1) when cauda equina syndrome is sus pec ted; (2) for ev alu atio n of progre ssive neurologic deficit; or (3) when bony lesion is suspected on the basis of other tests or imaging proc edu res. Except as specified in subitem s (1) to (3), CT scanning is not indicated in the first eight w eeks after an injury. Com puted tomography scanning is indicated after eight weeks 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. B. Magnetic reso nan ce im aging (M RI) scanning is indicated any time that one of the fo llowing con ditions is m et: (1) when cauda equina syndrom e is sus pec ted; (2) for ev alu atio n of pr og re ss ive neu rologic deficit; (3) when previous spinal surgery has been performed and there is a need to differentiate scar due to previous surgery from disc herniation, tumor, or hem orrhage; or (4) sus pec ted discitis. Except as specified in subitems (1) to (4), MRI scanning is not indicated in the firs t eight weeks after an injury. Magnetic resonance imaging scanning is indicated after eight weeks if the patient contin ues with symptoms and physical findings after the course of initial

5221.6100

STATE OF MINNESOTA

Treatment Parameter Rules (2) hem orrhage is sus pec ted; (3) tumor or vascular m alform atio n is sus pec ted; (4) infection or in flam m ato ry dis ease is suspe cted; or (5) unenhanced MRI scanning was equ ivoca l. Discog raph y is indicated w hen : (1) all of the following are pres ent: (a) back pain is the predominant com plaint; (b) the patient has failed to impro ve with in i ti a l n o n s u r g ic a l m ana gem ent; (c) other imaging has not established a diagnosis; and (d) lumbar fusion surgery is being considered as a therapy; or (2) there has been previous spinal su rg er y, a n d p s e u d o a r th r o s is , recurrent disc herniation, annular tear, or internal disc disruptio n is suspected. Com puted tom ography discography is indica ted w hen : (1) sciatica is the predominant complaint and l ateral di sc herniat ion is suspe cted; or (2) if appropriately performed discography is equivocal or paradoxical, with a normal X-ray pattern but a positive pain response, and an annular tear or intra-annu lar injection is susp ecte d. Nuclear isotope imaging (including technicium, indium, and gallium scans) are not indicated unless tum or, stress fracture, i n fe c t io n , a v a s c u l a r n e c ros is, o r inflamm atory lesion is suspected on the basis of history, physical examination findings, laboratory studies , or the resu lts of oth er im aging studies. Thermography is not indicated for the diagnosis of any of the clinical categories of low back conditions in part 5221.6200, sub part 1 , item A. Anterior-posterior (AP) and lateral X-rays of the lumbosacral spine are limited by sub item s (1) and (2). (1) They are ind icated in the following circu m stan ces : (a) when there is a history of significant acute trauma as the precipitating event of the patien t's condition, and fracture, dislocation, o r f r a c tu r e d is l o c at io n is sus pec ted; (b) w h e n the h i s to r y, s ig n s , symptoms, or laboratory studies indica te possible tum or, infection, or inflam m atory les ion;

C.

D.

E.

F.

nonsurgical care and if the patient's condition prevents the resumption of the regular activities of da ily life including regular vocational activities. Myelography is indicated in the following circu m stan ces : (1) may be substituted for otherwise indicated CT scann in g o r M RI scanning in accordance with items A and B, if those imaging m odalities are not loc ally available; (2) in addition to CT scanning or MRI scanning, if there are progress ive neurologic deficits or changes and CT scanning or MRI scanning has been negative; or (3) for preoperative evaluation in cases of surgical intervention, but only if CT scanning or MRI scanning have failed to provide a definite preoperative diagnos is. Com puted tom ography m yelography is indica ted in the follow ing circ um stan ces : (1) the patient's condition is predom inantly sciatica, and there has been previous s p i n al s u rg e ry, a n d t umo r is sus pec ted; (2) the patient's condition is predom inantly sciatica and there has been previous spinal surgery and M RI sc anning is equ ivoca l; (3) when spinal stenosis is suspected and the C T o r MRI scan ning is equ ivoca l; (4) in addition to CT scanning or MRI scanning, if there are prog ressive neurologic symptoms or changes and CT scanning or MRI scanning has been ne gative; or (5) for preoperative evaluation in cases of surgical intervention, but only if CT scanning or MR I scanning have failed to provide a definite preoperative diagnos is. Intravenous enhanced CT scanning is indicated only if there has been previous spinal surgery, and the imaging stu dy is being use d to differentiate s car due to previous surgery from disc herniation or tum or, but only if intrathecal contrast for CT-m yelography is contraindicated and MRI scanning is not available or is also con traindicated . Gadolinium enhanced MRI sc anning is indicated when: (1) there has been previous spinal surgery, and the im aging stu dy is being used to differentiate sc ar du e to previous surgery from disc herniation or tum or; TP-9

G.

H.

I.

J.

K.

5221.6100

STATE OF MINNESOTA

Treatment Parameter Rules provider m ust assign the patient at each visit to the appropriate clinical category accord ing 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 pa in co nform ing to a dermatom al di stri bu tio n a n d a c c o m p a n i e d b y anato m ically congruent motor weakness or reflex changes. T his part doe s no t apply to fractures of the lumbar spine, or back pain due to an infectious , imm unologic, metabolic, endocrine, neurologic, visceral, or ne oplastic diseas e pro ces s. (1) Regional low ba ck pain, includes referred pain to the leg above the knee unless it conform s to an L2, L3, or L4 dermatomal distribution and is a c c o m p a n i e d b y a nato m ica lly congruent motor weakness or reflex changes. Re giona l low back pain includes the diagnoses of lumbar, lum bosacral, or sacroiliac: strain, s p r a in , m y o f a s c i a l s y n d ro m e , musculoligamentous injury, soft tissue inju ry, s p o n d y lo s i s , a n d o t h er diagnoses for pain believe d 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 cod es 7 20 to 720.9, 721, 721.3, 721.5 to 721.90, 722, 722 .3, 722.32 , 722.5, 722.51, 722.52, 722.6, 722.9, 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, 847 .2 to 847.9, 922.3, 926.1, 926.11, and 926 .12. (2) Radicular pain, w ith or without regional low back pain, with static or no neurologic deficit. This includes the diagnoses of sciatica; lumbar or lumbosacral rad iculopath y, radiculitis or neuritis; displacement or herniation of intervertebral disc with myelopath y, radiculopathy, radiculitis or neuritis; spinal stenosis with m yelopathy, radiculopath y, radiculitis or neuritis; and any other diagnoses for pain in the leg below the kn ee believed to origina te 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, 722.2,

(c) for postoperative follow-up of lum bar fusion su rgery; (d) when the patient is more than 50 years of ag e; (e) before beginning a course of treatment with spinal adjustment or m anipulation; or (f) eight weeks after an injury if the patient contin ues with symptoms and physical fin din gs after the course of initial nonsurgical care and if the pa tient's condition prev ents the resumption of the regular activities of daily life in c l u d in g reg u l a r v o c a t io n a l activities. (2) They are not indicated in the following circu m stances : (a) to verify progress during initial nonsu rgical treatm ent; or (b) to evaluate a successful initial non surgical treatm ent program . L. Oblique X-rays of the lumbosacral spine are lim ited by subitem s (1) and (2). (1) They are indicated in the following circu m stances : (a) to follow up abnormalities detected on anterior-posterior or lateral X-ray; (b) for postoperative follow-up of lumb ar fusion surgery; or (c) to follow up spondylolysis or spondylolisthe sis not adequately diagnosed by other indicated imaging pro ced ures . (2) They are not indicated as part of a p a c k a g e o f X - r a y s i n cl u di n g anterior-posterior and lateral X-rays of the lum bos acral spine. M. Ele ctronic X-ray analysis of pla in radiographs and diagnostic ultrasound of the lumbar spine are not indicated for diagnosis of an y of the low back conditions in part 5221.6200, subpa rt 1, item A. STAT AUTH : MS s 176.103; 176.83 HIST: 19 SR 1412 522 1.62 00 L OW BAC K P AIN. Subpa rt 1. Diagnostic procedures for treatment of low back injury. A health care provider shall determine the nature of the condition before initiating treatm ent. A. An app ropriate history and physical exam ination must be performed and documented. Based on the history and physical examination the health care

TP-10

5221.6200

STATE OF MINNESOTA

Treatment Parameter Rules

722.7, 722.73, 724.0, 724.00, 724.02, 724.09, 724 .3, 724.4, and 7 24.9 . In these cases, neurologic findings on history and physical exam ination are either absent or do not show prog ressive d eterioration. (3) Radicular pain, w ith or without regional low back pain, with progressive neurologic deficit. This includes the sam e diagnoses as subitem (2), howeve r, this categ ory applies when there is a history of progressive d e te ri o ra tio n i n th e n eu rologic symptoms and physical findings which include worsening sensory loss, increasing muscle weakness, or prog ressive re flex chan ges . (4) Cauda equina syndrome, which is a syndrome characterized by anesth esia in the buttocks, genitalia, or thigh and accompanied by disturbed bowel and bladder func tion, ICD-9-CM codes 344 .6, 344.60 , and 344 .61. B. Laboratory tests are n ot indicated in the evaluation of a patient with regional low back pain, radicular pain, or cauda equina syndrome, except in any of the following circu m stan ces : (1) when a patie nt's history, age, or e x a mi n a tio n s u g g e s ts infecti on, m etabolic-endocrinologic disorders, t u m o r o u s c o n d i ti o n s , s y s te m i c musculoskeletal disorders, such as rheum ato id arthritis or ankylosing spo ndylitis; (2) to evaluate potential adverse side effects of m edications; or (3) as part of a pre ope rative e valua tion. Laboratory tests may be ordered at any time the health care provider sus pec ts any of these conditions, but the health care provider m ust justify the need for the tests ordered w ith clear documentation of the indications. C. Medical imaging evaluation of the lumbosacral spine m ust 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 m ay 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 docum ent the appropriate indications for any m edical im aging studies obtained. D. EMG and nerve c onduction studies are alw ays inapp ropriate for regional low back pain as defined in item A, subitem (1). TP-11

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 rad icu lar sym ptoms. Repe at EMG and nerve conduction studies for radicular pain and cauda equina syndrome are not indicated unless a new neurologic sym ptom or finding has developed which in itself would warrant electrodiagnostic testing. Failure to improve with treatment is not an indica tion for repeat testing. E. The use of the following procedures or tests is not indicated for the diagnosis of any of the clinical catego ries in item A: (1) surface electromyography or surface para spinal electrom yography; (2) therm ogra phy; (3) plethysm ogra phy; (4) electronic X-ray analysis of p lain radiograp hs; (5) diagnostic ultrasound of the lumbar spine; or (6) som atosenso ry evoked potentials (SSEP) and motor evoked potentials (MEP). F. Com puterized range of motion or stre ngth measuring tests are not indicated during t h e p e riod of in itial n o n s u r g ic a l m ana gem ent, but may be indicated during the period of chronic managem ent when used in conjunction with a computerized exerc i se program, wo rk ha rd en ing program , or work conditioning program. During the period of initial nonsurgical m ana gem ent, computerized range of motion or strength testing may be performed but must be done in conjunction with and shall not be reim bursed separately from an office visit with a physician, chiropractic evaluation or treatment, or physical or occupational therapy evaluation or trea tm ent. G. Personality or psychosocial evaluations may be ind icated for ev aluating pa tients who continue to have problems de spite app ropriate care. The treating health care provider may perform this evaluation or may refer the patient fo r con sultation with another hea lth care pro vider in orde r to obtain a psychological evaluation. These evaluations may be used to assess the patient for a number of psychological conditions which m ay 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

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STATE OF MINNESOTA

Treatment Parameter Rules

con sider 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, wh ich 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 interpe rsonal co nflicts interfering with recovery? (6) Does the patie nt have a chronic pain syndrome or psychogenic pain? (7) In cases in which surgery is a possible treatm ent, are psychological factors like ly 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, ne rve block , and nerve roo t block . (1) These procedu res are use d to loc alize the source of pain before surgery and to diagnose conditions which fail to r e s p o n d to in iti a l n o n s u r g ic a l m ana gem ent. (2) These injections are invasive and when done as diagnostic procedures only, are no t ind icated unless noninvasive proced ures have failed to esta blish the diag nos is. (3) Selection of patients, choice of procedure, and localization of the level of injection should be determined by documented clinical findings indicating poss ible pathologic conditions and the sou rce of pa in sym ptom s. (4) These blocks and injections can also be used as therapeutic modalities and as suc h are subject to the param eters of su bpa rt 5. I. Functional capacity assessment or evaluation is a comprehensive and objective ass ess m ent of a pa tient's ability to perform work tas ks. Th e co m pon ents of a functional capacity assessment or evaluation include, but are not limited to, neuromusculoskeletal screen ing, tests of manua l material handling, assessment of functional m obility, and measurem ent of postural toleran ce. A functiona l capa city a s s e s s m e n t o r e v a lu a t io n i s a n individualized testing process and the component tests and m easurem ents are determined by the patient's condition and the requ este d inform ation. Functional cap acity asses sm ents and eva luations are performed to determ ine an d rep ort a TP-12

patient's physical cap acities in gen eral or to determine work tolerance fo r a s pecific job, task , or wo rk activity. (1) Functional capacity assessm ent or evaluation is not indicated during the p e r io d o f i n i ti a l n o n s u r g ic a l m ana gem ent. (2) After the period of initial nonsurgical mana gement fun ctio na l ca pa city assessment or evaluation is indicated in eith e r of th e f o l lo w i n g circu m stan ces : (a) activity restrictions and capabilities m ust be identified; or (b) there is a question about the patient's ability to do a specific job. (3) A functional capacity evaluation is not app ropriate to establish baseline performance before treatment, or for subsequent assessments, to evaluate cha nge during or a fter treatm ent. (4) Only one completed functional capacity evaluation is indica ted per injury. J. Consultations with other health care providers can be initiated at any tim e by the treating health care provider cons istent w ith acc epte d m edical 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 determ ined by the clinica l categ ory to which the patient has been assigned. General parameters fo r trea t m en t modalities are set forth in subparts 3 to 10. Sp ecific treatment parameters for each clinical category are se t forth in s ubp arts 11 to 13, as follow s: (1) subpa rt 11 governs regional low back pain; (2) subpa rt 12 governs radicular pain with no or static neurologic deficits; and (3) subpa rt 13 governs cauda equina syndrom e and radicular pain with prog ressive n euro logic deficits. The health care provider must, at each visit, reassess the appropriateness of the clinical category assigned and reassign the patient if wa rrante d by new clinical information including symptoms, signs, results of diagnostic testing, and opinions a n d info rm atio n obtained from consultations with other health care providers. W hen the clin ical categ ory is changed, the treatment plan must be appropriately modified to reflect the new clinical category. However, a change of

5221.6200

STATE OF MINNESOTA

Treatment Parameter Rules

clinical categ ory does not in its elf allow the hea lth care provider to continue a therapy or treatment modality past the max im um duration specified in subparts 3 to 10, or to repeat a therapy or treatm ent previously prov ided for the sam e injury. B. In gen eral, a course of treatment is divided into thre e ph ase s. (1) First, all patients with low back problems, e x c e p t pa tien ts w ith progress ive neurologic deficit or cauda equina syndrom e under su bpart 1, item A, su bitem s (3) and (4), m ust be given initial nonsurgical management which m ay include active treatment m o d a l it ie s , p a s s i v e t r e a t m e n t modalities, injectio ns, durable medical equ ipm ent, and medications. These modalities and param eters are described in subparts 3, 4, 5, 8, and 10. The period of initial nonsurgical treatment beg ins with the first active, passive, medication, durable medical equipm ent, or injec tion m od ality initiated. Initial nonsurgical treatment must result in pr o g r e s siv e improvement as specified in subpart 9. (2) Second, for patients with persistent s y m p t o m s , i n i t i a l n o n s u r g ic a l managem ent is followed by a period of surgical evaluation. This evaluation should be completed in a timely m anner. Surg ery, if indicated, should be perform ed as expeditiously as poss ible consistent with sound medical practice and subparts 6 and 11 to 13, and part 5221.6500. The treating hea lth care provider may do the evaluation, if it is within th e provider's scope of pra ctice, or may refer the em ployee to a cons ultant. (a) Patients with radicular pain with progress ive neu rological deficit, or cauda equina syndrome m ay r e q u i r e i m m e d i a te s u r g ic a l thera py. (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 non surgical care. (c) S u r g e r y mus t follow th e parameters in subparts 6 and 11 to 13, and part 5221 .650 0. (d) A decision against surgery at this tim e does not preclude a decision for surge ry m ade at a later date . TP-13

(3) Third, for those patients who are not candidates for or refuse surgical the rapy, or who do not have co m plete resolution of their sym ptom s with su rg er y, a p e r io d o f c h ro n ic managem ent may be indicated. Chronic managem ent m odalities are described in part 5221.6600, and may include durable medical equipment as des cribed in su bpa rt 8. C. A treatin g health care provider m ay refer the employee for a consultatio n at any tim e during the course of treatment consistent with ac cep ted m edical practice. Subp. 3. Passive treatment modalities. A. Except as set forth in item B or part 5221.6050, subpart 8, the use of pas sive treatment modalities in a clinical setting as set forth in item s C to I is not indicated beyond 12 calendar weeks after any of the passive moda lities in item C to I are initiated. There are no limitations on the use of passive treatment modalities by the em ployee at hom e. 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 fo llowing app ly: (a) the employee is released to work or is permanently totally disabled and the ad ditio na l pa ss ive t r e at m e n t m u s t r e s u l t i n progressive improvement in, or m aintenance of, functional status achieved during the initial 12 wee ks of pa ssive care ; (b) the treatment must not be given on a regularly scheduled basis; (c) the health care provider must document in the med ical record a plan to encourage the em ploye e's independence and decreased reliance on health care providers; (d) managem ent of the em ploye e's condition must include active treatment m odalities during this period; (e) the additional 12 visits for passive treatm ent must not delay the required surgical or c hronic pain evaluation requi red by t his chapter; and (f) passive care is inapprop riate while the em ployee has chronic pain syndrom e. (2) Except as otherwise provided in part 5221.6050, subpart 8, treatment m ay continue beyond the additiona l 12 visits only after prior approval by the insurer,

5221.6200

STATE OF MINNESOTA

Treatment Parameter Rules

com m issioner, or compensation judge based on documentation in the medical record of the effectiv eness of f u r th e r p a s s i ve t re a t m e n t i n maintaining em plo yability; if the employee is perm an en tly 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, com m issioner, or compensation judge based on documentation in the medical record of the effectiveness of further passive treatment in maintaining functional status. C. Adjustment or m anipulation of joints includes chiropractic and osteopathic adju stm ents or m anipulations: (1) tim e for treatm ent re spo nse , three to five trea tm ents ; (2) maxim um treatm ent fre que ncy, up to five times per week for the first one to two weeks decreasing in frequency thereafter; and (3) maxim um treatm ent duration, 12 wee ks. D. Thermal treatment includes all superficial and deep heating and cooling mod alities. Superficial thermal m odalities include hot packs, hot soaks, hot water bottles, hydrocollators, heating pads, ice packs, cold soa ks, infrare d, wh irlpool, and fluidothe rapy. Deep thermal modalities include diathermy, ultrasound, and m icrow ave. (1) Treatm ent given in a clinical setting: (a) tim e for treatment response, two to four treatm ents ; (b) maxim um treatment frequency, up to five times per week for the first one to th ree weeks decreasing in frequency thereafter; and (c) maxim um treatm ent duration, 12 weeks of treatment in a clinical setting but only if given in con junc tion with other thera pies. (2) H om e use of therm al mod alities may be pre sc ribed at any time during the course of treatment. Home use m ay only involve hot packs, hot soaks, hot water bottles, hydrocollators, heating pads, ice pack s, a nd cold soaks which can be applied by the patient without hea lth care provider assistance. Home use of thermal modalities does not require any sp ecia l training or monitoring, other than that us ually TP-14

provided by the health care provider during an office visit. E. Electrical muscle stimulation includes galvanic stimulation, TEN S, interferential, and m icroc urrent techniques . (1) Treatm ent given in a clinical setting: (a) tim e for treatment response, two to four treatm ents ; (b) maxim um treatm ent fre quency, up to five tim es per week for the first one to three weeks decreasing in frequency thereafter; and (c) m aximu m treatm ent d uratio n, 12 weeks of treatm ent in a clinical setting but only if given in con junc tion with other thera pies. (2) H om e use of an electrical stimulation device m ay b e prescribed at any tim e 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 patien t education : (a) tim e for patient education and training, one to three sessions; and (b) patient m ay use the electrical stimulation device for one mon th, at which time effectiveness of the treatment must be reevaluated by the health care provider before continuing home use of the device. F. Me cha nical traction: (1) Treatm ent given in a clinical setting: (a) tim e for treatment response, three treatm ents ; (b) maxim um treatment frequency, up to three times per week for the first one to three weeks decreasing in frequency thereafter; and (c) maxim um treatmen t duration, 12 we ek s in a clinical setting but only if used in conjunction with other thera pies. (2) H om e use of a m ech anical 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 treatm ent. Initial use of a mechanical traction device must be in a supervised setting in order to ensure prop er pa tient educa tion: (a) tim e 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

5221.6200

STATE OF MINNESOTA

Treatment Parameter Rules

the health care provider before continuing home use of the device. G. A c u p u n c t u r e treatm ents . Endorphin-mediated analgesic therapy i n cl u d e s c l a s si c a c u p un c t u re a n d acu pres sure: (1) tim e for treatm ent re spo nse , three to five se ssions; (2) maxim um treatm ent fre que ncy, up to three times per week for one to three weeks de crea sin g in frequency thereafter; and (3) m aximum treatment duration, 12 wee ks. H. Manual therapy includes soft tissue and joint mobilization, therapeutic massage, and m anu al traction: (1) tim e for treatmen t respons e, three to five trea tm ents ; (2) maxim um treatm ent fre que ncy, up to five times per week for the first one to two weeks decreasing in frequency thereafter; and (3) maxim um treatment duration, 12 wee ks. I. Ph oresis includes iontophoresis and pho nop hore sis: (1) tim e for treatm ent re spo nse , three to five se ssions; (2) maxim um treatm ent fre que ncy, up to three tim es per week for the first one to three weeks decreasing in frequency thereafter; and (3) maxim um treatment is nine sessions of e i th e r io n t o p h o r e s i s or phonophoresis, or combination, to any one site, with a maxim um duration of 12 w eek s for all treatm ent. J. Bedres t. Prolonge d res triction of activity and imm obilization a re de trim enta l to a patient's recovery. Bedrest should not be pres cribed for m ore th an s even da ys. K. S p i n a l braces and other movem ent-restricting appliances. Bracing required for longer than two weeks must be accom panied by a c t iv e m u s c l e s t r e n g t h e n i n g e x e r c is e t o a vo id dec ond itioning and p rolonged disab ility: (1) tim e for treatment response, three days; (2) treatment frequency, limited to intermittent use during times of i n c re a s e d p h y s ic a l s tr e s s o r prophylactic use at work; and (3) maxim um continuous duration, three weeks unless patien t is status pos tfusion. Subp. 4. Active treatment m odalities. Active treatment modalities must be used as set TP-15

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 maxim um duration for the active modality is not exc eed ed. A. Education must teach the patient about pertinent anato m y and physiology as it relates to spinal function for the purpose of injury prevention. Education includes training on posture, biom echanics, and relaxation. The m aximum number of treatm ents is three visits, which includes an initial education and training session, and two fo llow-up visits. B. Posture and work method training must instruct the patient in the proper perform ance of job activities. Topics include proper positioning of the trunk, neck, and arm s, use of optim um biomechanics in performing job tasks, and appropriate pacing of activities. Methods include didactic sessions, demonstrations, exercises, and simulated work tasks. The maxim um number of treatments is three visits. C. W ork site analysis and modification must examine the patient's work station, tools, and job duties. Recom m endations are made for the alteration of the work station, selection of alternate tools, modification of job duties, and provision of adaptive equ ipm ent. The m aximum number of treatm ents is three visits. D. Exercise, which is important to the success of an initial nonsurgical treatment program and a re turn to norm al activity, must include active patien t participation in activities designed to increase fle xibility, strength, endurance, or muscle relaxation. Exercise must, at least in part, be specifically aimed at the musculature of the lumbosacral spine. W hile aerobic exercise and extremity strengthening m ay be performed as adjun ctive treatm ent, 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 objec tively measured. W hile the provider m ay obje ctively m easure 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 m onthly thereafter. Subitems (1) and (2) govern supervised and unsupervised exercise, except for computerized exercise

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Treatment Parameter Rules

programs and health clubs, which are governe d by pa rt 522 1.66 00. (1) Supervised exercise. One goal of an exercise program must be to teach the patient how to maintain and m axim ize any gains experienced from exercise. Self-management of the condition m ust be pro m oted : (a) m aximum treatm ent fre quency, three tim es per week for three weeks, and should decrease in frequency thereafter; and (b) m axim um dura tion, 12 wee ks. (2) Unsupervised exercise must be provided in the least intensive setting app ropriate to the goals of the exercise program, and may supplement or follow the period of supervised exe rcise : (a) maxim um treatment frequency, up to three visits for instruction and monitoring; and (b) there is no limit on the duration or frequen cy of exercise at hom e. Subp. 5. Therapeutic injections. Injection modalities are ind icated as s et forth in item s A to C. Use of injections can extend past the 12-week lim it on passive treatment modalities so long as the m axim um treatment for injections is not exc eed ed. A. Therapeutic injections, including injections of trigger points, facet joints, facet nerves, sacroiliac joints, sympathetic nerves, epidurals, nerve roots, and peripheral nerves. Th erapeutic injections can only be given in conjunction with active treatment modalities directed to the same anatomical site. (1) Trigger point injection s: (a) tim e for treatment res ponse, w ithin 30 m inutes ; (b) max imum treatm ent fre quency, once per week to any one site if a positive response to the first injection at that site. If subsequent injections at that site de m ons trate diminishing control of symptom s or fail to fac ilitate objective functional gains, then trigger point injections should be redirected to other areas or discontinued. No m ore than three injections to different sites are reim bursable per patient visit; and (c) m a x i m u m treatm ent, f o ur injections to any on e site. (2) Sacroiliac joint injec tions: (a) tim e for treatment response, with in one wee k; TP-16

(b) maxim um treatment frequency, can repeat injection two weeks after the pre vious injectio n if a positive response to the first injection. Only two injections are reim bursable per patien t visit; and (c) maxim um treatm ent, two injections to any one s ite. (3) Facet joint or ne rve inje ctions : (a) tim e for treatment response, with in one wee k; (b) m axim um treatm ent fre quency, once every two weeks to any one site if a positive response to the first injection. If subsequent injections demonstrate dim inishing control of sym ptom s or fail to facilitate objective functional gains, t h e n i n je c t io n s s h o u l d be discontinued. No m ore than three injections to different s ites are reim bursable per patien t visit; and (c) maxi m um treatm ent, t hre e injections to any on e site. (4) Ne rve ro ot bloc ks: (a) tim e for treatment response, with in one wee k; (b) maxim um treatm ent fre quency, 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) m aximum treatment, two injections to any one s ite. (5) Epidural injections: (a) tim e for treatment response, with in one wee k; (b) m axim um treatm ent fre quency, once every two weeks if a positive response to the first injec tion. If subsequent injections dem onstrate diminishing control of symptoms or fail to facilitate objective functional gains, then injections should be discontinued. Only one injectio n is reim bursable per patien t visit; and (c) maxi m um treatm ent, three injections. B. Permanent lytic or sclerosing injections, including radio frequency denervation of the facet joints. These injectio ns can only be given in conjunction with active treatment mod alities directed to the same ana tom ical site: (1) tim e for treatment response, within one wee k; (2) maxim um treatment frequency, may

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repeat once for any site; and (3) maxim um duration, two injection s to any on e site. C. Prolotherapy and botulinum toxin injections are not indicated in the treatment of low bac k problem s an d are not reimburs able. Subp. 6. Surg ery, including decomp ression procedures and arthrodesis. Surgery m ay only be perform ed if it als o m eets th e specific param eters spe cified in sub parts 11 to 13 and part 5221.6500. The he alth care provider must provide prior notification of nonemergency inpatient surgery acco rding to part 522 1.60 50, subp art 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 max im um treatm ent duration with passive treatm ent mod alities in a clinical setting from the initiation of the first passive mod ality used, except bedrest or bracing, is as follows : (1) eight weeks following lumba r decompression or implantation of a dorsal column stimulator or morphine pum p; or (2) 12 w eek s follow ing arthrod esis. B. Repeat surgery must also meet the param eters of subparts 11 to 13 an d part 5221.6500, and is not indicated unless the need for the repeat surgery is confirmed by a second opinion obtain ed before surgery, if a second opinion is requested by the insurer. C. The following surgical therapies have very limited application and require a second opinion that confirm s th at th e treatm ent is indicated and with in the parameters listed, and a perso na lity or p syc ho so cia l evaluation that indicates that the patient is likely to benefit from the treatm ent. (1) Dorsal column stimulator is indicated for a patient who has neuropathic pain, and is not a candidate for any other surgical therapy, and has had a favorable resp ons e to a trial screening period. (2) Morph ine pum p is indicated for a patient who has som atic pain, and is not a candidate for any other surgical therapy, and has had a favorable respon se to a trial screen ing pe riod. Subp. 7. Chronic m anag em ent. Ch ronic managem ent of low back pain must be provided acc ording to the para m eters of pa rt 522 1.66 00. Subp. 8. Du rable m edical equipme nt.

Durable medical equipment is indicated only in the situ atio ns spe cified in item s A to D. T he h ealth care provider m ust provide prior notification as required in items B and C according to part 522 1.60 50, subp art 9. A. Lumbar braces, corse ts, 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 with in 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 m ay provide equipm ent if it is com parable to that prescribed by the health care pro vider. C. Exercise equipm ent for home use, i ncludi ng bi cycl es, treadmi lls, and stairclimbers, are indicated only within the context of a program or plan of an approved chronic managem ent program . This equipment is not indicated during i nitial nonsurgical care or du rin g reevaluation and surgical therapy. Prior notification must be provided to the insurer for the purchase of hom e exercise equ ipm ent. The insurer may decide which brand of a prescribed type of exercise equipment is provided to the p atient. If the employer has an ap propriate exercise facility on its premises with the prescribed equipment, the insurer may mandate use of that facility instead of authorizing purchase of the equipm ent for home use. (1) I n di cati ons: the patient is d e c o n d i ti o n e d and r e q uires r e c o n d i ti o n in g w h i c h c a n b e accomplished only with the use of the prescribed exercise equipment. The hea lth care provider m ust document specific reasons why the exercise equipment is necessary and cannot be replaced with oth er ac tivities. (2) Requirements: the use of the equipment must have specific goals and there must be a specific set of pres cribed ac tivities. D. The following durable m edical equipm ent is not indicated for home use for low back con ditions: (1) whirlpools, Jacuzzi, hot tubs, and special bath or shower attachments; or (2) beds, waterbeds, mattresses, chairs, recliners, and lou nge rs. Subp. 9. Evaluation of treatment by health care prov ider. The health care provider must evaluate at each visit whether the treatm ent is

TP-17

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Treatment Parameter Rules

m edically necessary, and must evaluate whether initial nonsurgical treatment is effective according to item s A to C. No later than the time for treatment res ponse esta blished fo r the specific m oda lity as specified in subparts 3, 4, and 5, the hea lth care provider must evaluate whether the passive, active, injection, or medication treatment m oda lity is resulting in progressive improvement as s pec ified in item s 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 sym ptom s; B. the objective clinical findings are progress ively improving, as evidenced by doc um enta tion in the medical record of resolution or obj e c ti v ely mea sure d improvement in physical signs of the injury; and C. the employee's functio nal status , es pecially vocational activity, is progressively improving, as evidenced by documentation in the m edical record, or succes sive repo rts of wo rk ability, of less restrictive imitations on activity. If there is not progressive improvem ent in at least two items of items A to C, the m oda lity must be discontinued or significantly modified, or the provider must reconsider the diagnosis. The evaluation of the effectiveness of the treatment m oda lity can be delegated to an allied health professional directly providing the treatm ent, but remains the ultimate respon sibility of the treating health care prov ider. Subp. 10. Scheduled and nonscheduled medication. Prescription of controlled substance medications sch edu led un der M innesota Statutes, section 152.02, including without limitation, narcotics, is indicated only for the treatment of severe acute pain. These medications are not indicated in the treatm ent of patients with regional low back pain a fter the first two wee ks. Patients with rad icular pain may require longer periods o f treatm ent. The health care provider must document the ration ale for the use of any scheduled medication. Treatment with nonscheduled medication may be app ropriate during any phase of treatment and inte rm itten tly after all other treatment has been discontinued. The prescribing health care provider m ust determ ine that ongoing m edication is effective treatment for the patient's condition and that the m ost c ost-e ffec tive reg imen is u sed . Subp. 11. Spe cific treatm ent p aram eters

for regional low back pain. A. Initial nonsurgical treatment m ust be the first phase of treatment for all patien ts with regional low back pain under subpart 1, item A, su bitem (1). (1) The passive, ac tive, inje ctio n, durable medical equipment, and medication treatment modalities and procedures in subparts 3, 4, 5, 8, and 10, may be used in sequence or sim ultan eously during the period of initial nonsurgical m anagement, depending on the severity of the con dition. (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 trea tm ent, initial nonsurgical treatment must at all times conta in active treatment modalities according to the param eters of subpa rt 4. (4) Initial nonsurgical treatment m ust be provided in the least intensive setting consistent with quality health care prac tices. (5) Except as otherwis e specified in s u b p a r t 3 , p a s s iv e t re a tm e n t modalities in a clinic settin g 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 managem ent is indicated if the patien t 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 non surgical care. If the patient is not a surgical candidate, then chronic m ana gem ent is ind icated . (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 managem ent. An initia l recomm endation or decision against surgery does not prec lude surg ery at a later da te. (2) Surgical evaluation may include the

TP-18

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Treatment Parameter Rules

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 param eters of part 5221.6100. Medical im aging stu dies which do not meet these param eters are n ot indicated . (3) Surgical evaluation may also include diagnostic blocks and injections. These blocks and injectio ns are only indicated if their use is con sistent with the param eters of su bpa rt 1, item H. (4) Surgical evaluation may also include pers ona lity or psychosocial evaluation, consistent with the parameters of sub part 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 f in d i n g s on m ed ica l im a g in g , diagnostic analgesic blocks and injections, if performed, and the patient's ongoing subjective com plaints and physical findings. (6) The only surgical procedures indicated for patien ts with regional low back pain only are decompression of a lumb ar nerve root or lumbar a rthrodes is, with or without instrumentation, which must meet the parameters of subpart 6 and part 5221.6500 , subpart 2, items A and C. For pa tients with failed back surgery, dorsal column stimulators or morphine pumps m ay be indicated; the ir use must meet the parameters of sub part 6 , item C. (a) If surgery is indicate d, it should be offered to the patient as soon as possible. If the patient agrees to the pro posed surgery, it should be performed as expeditiously as poss ible consistent with sound medical practice, and consistent with any requireme nts of part 5221.6050, subpart 9, for prior notification of the insurer or sec ond 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 m anagement according to the parameters of part 5 221 .660 0. C. If the patient c ontinu es w ith symptoms and objec tive physical findings after surgical TP-19

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 m ana gem ent w hich m ust be provided according to the parameters of part 5 221 .660 0. Subp. 12. Spe cific treatm ent p aram eters for radicular pain, with or without regional low back pain, with no or static neurologic deficits. A. Initial nonsurgical treatment is app ropriate for all patients with radicular pain, with or without regional low back pain, with no or sta tic neurologic deficits under subpart 1, item A, subitem (2), and must be the first phase of treatment. It must be provided with in the parameters of subpart 11, item A, with the following modifications: epidural blocks, and nerve root and peripheral nerve blocks are the only the rapeutic injections indicated for patien ts with radicular pain only. If there is a component of regional low back pain, the rapeutic facet joint injections, facet nerve injections, trigger point injections, and sacroiliac injections may also be indica ted. B. Surgical evaluation or chronic management is indicated if the patien t continu es w ith 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 da ily life including regular vocationa l activities. It m ust be provided within the param eters of subpa rt 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 patien t'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 m anagem ent. An y course or program of chronic management for patien ts with radicular pain, with or without regional back pain, with static neurologic deficits must m eet all of the parameters of part 5 221 .660 0. Subp. 13. Spe cific treatm ent p aram eters for cauda equina syndrome and for radicular pain, with or without regional low back pain,

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Treatment Parameter Rules diagnosis m ust be do cum ente d in the medical record. For the purposes of subitems (2) and (3), "radicular pain" means pain radiating distal to the shou lder. This part does not apply to fractures of the cervical spine or cervical pain due to an i nfectious , im m un olo gic , m eta bo lic, endocrine, neu rolog ic, visce ral, or neo plastic disease proc ess . (1) Regional neck pain includes referred pain to the shoulder and upper back. Regional neck pain includes the diagnoses of cervical strain, sprain, m yo f a s c ia l s y n d ro m e , musculoligamentous injury, soft tissue inju ry, and othe r dia gnoses for pain believed to originate in the discs, ligaments, muscles, or other soft tissues of the cervical spine and which affects the cervical region, with or without referral to the upper back or shoulder, including, bu t not lim ited to, ICD-9-CM codes 720 to 720.9, 721 to 721.0, 721 .5 to 72 1.90 , 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 92 6.12 . (2) Radicular pain, w ith or without regional neck pain, w ith no or static neurologic deficit. This includes the diagnoses of brachialgia; cervical ra diculopathy, radiculitis, or neuritis; displacement or herniation of intervertebral disc with radiculopathy, rad iculitis, or neuritis; spinal stenosis with radiculopath y, radiculitis, or neuritis; and other diagnoses for pain in the arm distal to the shou lder believed to originate with irritation of a nerve root in the cervical spine, including, but not limited to, the 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. In these cases neurologic findings on history and examination are either absent or do not show prog ressive d eterioration. (3) Radicular pain, w ith or without regional neck pain, w ith progressive neurologic deficit, which includes the same diagnoses as subitem (2); howeve r, in these cases there is a history of progress ive deterioration in the neurologic sym ptoms and physical findings, including worsening sens ory loss, increasing m usc le weaknes s, and progressive reflex changes.

with progressive neurologic deficits. A. Patients with cauda equina syndrome or with radicular pain, with or without regional low back pain, w ith pro gressive neurologic deficits may require imm ediate or emergency surgical evaluation at any tim e during the course of the overall treatm ent. The decision to proceed with surgical evaluation is mad e by the health care provider based on the type of n eurologic changes obs erve d, the severity of the changes, the rate of progression of the changes, and the response to any initial nonsurgical treatm ents. Surgery, if indicated, m ay be perform ed at any tim e during the cours e of tre atm ent. S urgical evaluation and surgery shall be provided with in the param eters of subpart 11, item B, exc ept that surgical evalua tion and surgical therap y may beg in at an y time. B. If the health care provider decides to proceed with a course of initial nonsurgical care for a p atient w ith radicular pain with progress ive neu rologic chang es, it mus t follow the parameters of subpart 12, item A. C. If the patient continues with symptoms and objective physic al 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 managem ent. Any course or program of chronic management for patien ts with radicular pain, with or without regional back pain, with foot drop or progress ive neu rologic chang es a t first presentation must meet the parameters of part 5 221 .660 0. STAT AUTH : MS s 176.103; 176.83 HIST: 19 SR 1412 522 1.62 05 N EC K P AIN. Subpa rt 1. Diagnostic procedures for treatment of neck injury. A health care provider shall determine the nature of the condition before initiating trea tm ent. 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

TP-20

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STATE OF MINNESOTA

Treatment Parameter Rules

B.

C.

D.

E.

(4) Cervical com pres sive m yelopa thy, with or without radicular pain, is a condition characterized by weakness and spa sticity in one or both legs and associated with any of the following: exaggerated reflexes, an extensor plantar res ponse, bow el or bla dder dysfunction, sensory ataxia, or bilateral sen sory change s. Laboratory tests are not indicated in the evaluation of a patient with regional neck pain, or rad icular p ain, ex cep t: (1) when a patient's history, age, or e x a mi n a tio n sugges ts infec tion, metabolic-endocrinologic disorders, t u m o r o u s c o n d i ti o n s , s yste m ic musculoskeletal disorders , such as rheum ato id arthritis or ankylosing spo ndylitis; (2) to evaluate potential adverse side effects of m edications; or (3) as part of a p reoperative evaluation. Laboratory tests may be ordered at any time the health care provider sus pec ts any of these conditions, but the health care provider m ust justify the need for the tests o rdered w ith clear documentation of the indications. Medical imaging evaluation of the cervical spine must be based on the findings of the history and physical examination and cannot be ordered prior to the health care pro vider's clinical evaluation of the patien t. Medical imaging may not be performed as a routine procedure and m ust c om ply with the standards in part 5221.6100, subpart 1. The health care provider must document the appropriate indications for any medical imaging studies obtained. EMG and nerve c onduction studies are alw ays inapp ropriate for the regional neck pain diagnoses in item A, subitem (1). EMG and nerve conduction studies may be an appropriate diagnostic tool for radicular pain and m yelopathy diagnoses in item A, subitems (2) to (4), after the first three weeks of r ad icu lar or m yelopa thy symptoms. Repea t EMG and nerve conductio n studies for radicular pain and myelopathy 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 repea t testing. The use of the following procedures or tests is not indicated for the diagnosis of any of the clinical catego ries in item A: (1) surface electromyography or surface TP-21

para spinal electrom yography; (2) therm ogra phy; (3) plethysm ogra phy; (4) electronic X-ray analysis of pla in radiograp hs; (5) diagnostic ultrasound of the spine; or (6) som atosenso ry evoked po tentials (SSEP) and m otor evok ed poten tials (MEP). F. Com puterized range of motion or stre ngth meas uring tests are not indicated during t h e p e r io d o f i n i ti a l n o n s u r g i c al m ana gem ent, but may be indicated during the period of chronic management when used in conjunction with a computerized exercise program, w ork ha rd en ing program , or work conditioning program. During the period of initial nonsurgical m ana gem ent, computerized range of motion or strength testing can be performed but must be done in conjunction with and shall not be reim bursed separately from an office visit, chiropractic evaluation or treatmen t, or ph ysical or occupational thera py eva luation or trea tm ent. G. Personality or psychological evaluations may be a useful tool for evaluating patien ts who con tinue to have pro blem s de spite app ropriate care. The treating health care provider may perform this evaluation or may refer the patient for con sultation 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 m ay interfe re with recovery from the injury. Since more than one of these psychological conditions may be pres ent in a given cas e, the hea lth care provider perform ing the evaluation must con sider 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 interpers ona l conflicts interfering with recovery? (6) Does the patient have a chronic pain syndrome or psychogenic pain? (7) In cases in which surgery is a poss ible treatm ent, are psychological factors, such as those in subitem s (1) to (6), like ly to interfere with the potential benefit of the surgery?

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Treatment Parameter Rules

H. Diagnostic analgesic blocks or injection studies include facet joint injection, facet nerve block, epidural differential spinal block, ne rve block , and nerve roo t block . (1) These procedu res are use d to loc alize the source of pain prior to surgery and to diagnose conditions which fail to r e s p o n d to in iti a l n o n s u r g ic a l m ana gem ent. (2) These blocks and injections are invasive and when done as diagnostic procedures only, are not indicated unless noninvasive proced ures have failed to establish the diag nos is. (3) Selection of patients, choice of procedure, and localization of the level of injection should be determined by documented clinical findings indicating poss ible patho logic conditions and the sou rce of pa in sym ptom s. (4) These blocks and injections can also be used as therapeutic modalities and as suc h are subject to the param eters of su bpa rt 5. I. Functional capacity assessment or evaluation is a comprehensive and objective ass ess m ent of a pa tient's ability to perform work task s. The com ponents of a functiona l capa city assess m ent or evaluation include, but are not necessarily limited to, neuromusculoskeletal screening, tests of manual material handling, assessment of functional mob ility, and measurem ent of postural tolerance . A functional cap acity as ses sm ent o r evaluation is an individualized testing process and the component tests and m eas urem ents are determined by the patient's condition and the requested i n f o r m a t io n . F u n c t io n a l ca pa cit y a s s e ssm ents a n d e v a lu a tio ns a re performed to de term ine a patient's physical capacities in general or to determine and report work tolerance for a specific job, tas k, or w ork a ctivity. (1) Functional capacity assessment or evaluation is not reimbursable during the period of initial nonoperative care. (2) Functional capacity assessment or evaluation is reimbursable in either of the fo llowing circum stan ces : (a) permanent activity restrictions and capab ilities m ust be identified; or (b) there is a question about the patient's ability to do a specific job. J. Consultations with other health care providers m ay be initiated at an y time by the treating health care provider, consistent with ac cep ted m edical practice. TP-22

Subp. 2. Ge nera l treatm ent p aram eters for neck pain. A. All medical care for neck pain appropriate ly assigned to a clinical categ ory in subpart 1, item A, is determined by the diagnosis and clinical category in s ubp art 1, item A, to which the patient has been assigned. General paramete rs for treatm en t modalities are s et forth in sub parts 3 to 10. Sp ecific treatm ent param eters for each clinical category are set fo rth in su bpa rts 11 to 14, as follow s: (1) subpa rt 11 governs regional neck pain; (2) subpa rt 12 governs radicular pain with static n euro logic deficits; (3) subpa rt 13 governs radicular pain with progressive neurologic deficits; and (4) sub part 1 4 go vern s m yelopa thy. The health care provider m ust, 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 a n d info rm atio n o bta ine d from consultations with other health care providers. W hen the clinica l categ ory 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 hea lth care provider to continue a therapy or treatmen t modality past the maximum duration specified in sub parts 3 to 10, or to repeat a therapy or tre atm ent previously prov ided for the sam e injury. B. In general, a course of treatment is divided into thre e ph ase s. (1) First, all patients with neck problems, except patien ts with radicular pain with progressive neurological deficit, or myelopathy under subpart 1, item A, subitems (3) and (4), must be given initial nonsurgical care which may include both active and passive treatment moda l ities, inj ec tions, durable medical equipment, and medications. These modalities and para m eters are d esc ribed in sub parts 3, 4, 5, 8, and 10. The period of initial nonsurgical m ana gem ent begins with the first passive, active, injection, du ra ble medical equipm ent, or medication modality initiated. Initial nonsurgical treatm ent m ust result in progress ive improvement as specified in sub part 9 . (2) Second, for patients with persistent

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Treatment Parameter Rules

symptoms, initial nonoperative care is followed by a period of surgical evaluation. This evaluation should be completed in a tim ely m anner. Surgery, if indicated, should be performed as expeditiously as possible consistent with sound medical practice, and sub parts 6 and 11 to 14, and part 5221.6500. The treating health care provider m ay do th e evaluation, if it is with in the provider's scope of practice, or may refer the employee to a con sultan t. (a) Patients with rad icular pain with progress ive neurological deficit, or m y e lo p a t h y m ay re qu ire imm ediate surgical therap y. (b) Any patient who has had surgery may require postoperative therapy with active and passive treatm ent modalities. This therapy may be in addition to any received during the period of initial nonsurgical m ana gem ent. (c) Su rg e ry must f o llow th e param eters in subparts 6 and 11 to 14, and part 5221 .650 0. (d) A decision against surgery at th is tim e does not preclude a decision for surge ry m ade at a later date . (3) Third, for those patients who are not candidates for or refuse surgical the rapy, or who do not have co m plete resolution of the ir sym ptom s with su rg er y, a p e r io d o f c h ro n ic managem ent m ay be indicated. Chronic m anagem ent m odalities are described in part 5221.6600, and may include durable medical equipment as des cribed in su bpart 8. C. A treating health care provider may refer the employee for a consulta tion at any tim e during the course of treatment consistent with ac cep ted m edical practice. Subp. 3. Passive treatment modalities. A. Except as s et forth in item B or part 5221.6050, subpart 8, the use of pas sive treatment modalities in a clinical setting as set forth in item s 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 em ployee at hom e. 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 fo llowing app ly: (a) the employee is released to work TP-23

or is permanently totally disabled and the ad ditio na l pa ss ive t r e at m e n t m u s t r e s u l t i n progressive improvement in, or maintenance of, functional status achieved during the initial 12 wee ks of pa ssive care ; (b) the treatment must not be given on a reg ularly sched uled bas is; (c) the health care provider must document in the medical record a plan to encourage the em ploye e's independence and decreased reliance on health care providers; (d) managem ent of the em ploye e's condition must include active treatment m odalities during this period; (e) the additional 12 visits for passive treatment m ust not delay the required surgical or chronic pain ev alu atio n requ ired b y this chapter; and (f) passive care is inappropriate w hile the employee has chronic pain syndrom e. (2) Except as otherwise provided in part 5221.6050, subpart 8, treatment m ay continue beyond the additional 12 visits only after prior approval by the insurer, com m issioner, or compensation judge based on docum entatio n in the medical record of the effectiveness of f u r th e r p a s s i v e t r e a t m e n t i n maintaining em ployab ility; if the employee is perm an en tly tota lly 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, com m issioner, or compensation judge based on documentation in the medical record of the effectiveness of further passive treatment in maintaining functional status. C. Adjustmen t or m anipulation of joints includes chiropractic and osteo pathic adjustments or manipulations: (1) tim e for treatm ent re spo nse , three to five trea tm ents ; (2) maxim um treatm ent fre que ncy, up to five times per week for the first one to two weeks decreasing in frequency thereafter; and (3) maxim um treatm ent duration, 12 wee ks. D. Thermal treatment includes all superficial

5221.6205

STATE OF MINNESOTA

Treatment Parameter Rules treatment must be reevaluated by the health care provider before continuing home use of the device. Me cha nical traction: (1) Treatm ent given in a clinical setting: (a) tim e for treatment response, three treatm ents ; (b) maxim um treatment frequency, up to three times per week for the first one to three weeks decreasing in frequency thereafter; and (c) maxim um treatment duration, 12 weeks in a clinical settin g, but only if use d in co njun ction with other thera pies. (2) H om e use of a mechanical traction device may be prescribed as follow-up to use of tractio n in a clinical settin g 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 prop er pa tient educa tion: (a) tim e for patient education and training, one session; and (b) a 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. Acupuncture treatm ents . En dorphin-mediated analgesic therapy incl udes cla s s i c a c u p un c t u re a n d acu pres sure: (1) tim e for treatment response, three to five se ssions; (2) maxim um treatm ent fre que ncy, up to three times pe r week fo r one to three weeks decreasing in frequency thereafter; and (3) m aximum treatment duration, 12 wee ks. Manual therapy includes soft tissue and joint mob ilization, therapeutic massage, and m anu al traction: (1) tim e for trea tm ent re spo nse , three to five trea tm ents ; (2) maxim um treatm ent fre que ncy, up to five times per wee k fo r the firs t one to two week s decreasing in frequency thereafter; and (3) maxim um treatment duration, 12 wee ks. Ph oresis includes iontophoresis and pho nop hore sis: (1) tim e for treatm ent re spo nse , three to five se ssions;

and deep heating modalities and cooling modalities. Superficial thermal modalities include hot packs, hot soak s, hot water bottles, hydrocollators, he ating p ads , ice packs, cold soaks, infrared, whirlpo ol, and fluidothe rapy. Deep therm al m oda lities include diathermy, ultrasound, and m icrow ave. (1) Treatm ent given in a clinical setting: (a) tim e for treatment response, two to four treatm ents ; (b) maxim um treatm ent fre quency, up to five times per week for the first one to three weeks decreasing in frequency thereafter; and (c) maxim um treatment duration, 12 weeks of treatment in a clinical setting, but only if given in conjunction with other therapies. (2) H om e use of thermal m odalities may be prescribed at any time during the course of treatment. Home use m ay 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 hea lth care pro vider assistance. H om e use of thermal modalities does not require any special training or m onitoring, other than that usually provided by the health care provider during an office visit. E. Electrical m uscle stim ulation includes galvanic stim ulation , TEN S, in terferentia l, and m icroc urrent techniques . (1) Treatm ent given in a clinical setting: (a) tim e for treatment response, two to four treatm ents ; (b) maxim um treatm ent fre quency, up to five times per week for the first one to three weeks decreasing in frequency thereafter; and (c) m aximum treatment duration, 12 weeks of treatm ent in a clinical setting, but only if given in con junc tion with other thera pies. (2) H om e use of an electrical stimulation device m ay be presc ribed at any tim e during a course of treatment. Initial use of an electrical stimulation device must be in a supervised setting in orde r to ensure pro per ele ctrode placement and patien t education : (a) tim e for patient education and training, one to three sessions; and (b) patient m ay use the electrical stimulation device for one month, at which time effectiveness of the TP-24

F.

G.

H.

I.

5221.6205

STATE OF MINNESOTA

Treatment Parameter Rules

(2) maxim um treatm ent fre que ncy, up to three times p er week for the first one to three weeks decreasing in frequency thereafter; and (3) maxim um treatmen t duration, 12 wee ks. J. Bedres t. Prolonge d res triction of activity and im m obilizatio n are detrim ental to a patient's recovery. Bedrest should not be pres cribed for m ore th an s even da ys. K. Cervical collars, spinal braces, and other movem ent-restricting appliances. Bracing required for longer than two weeks m ust be a c c o m p a n i e d b y a ct iv e muscle s t r e ng t h e n in g e x e r c is e t o a vo id dec ond itioning and p rolonged disab ility: (1) tim e for treatment response, three days; (2) treatment frequency, lim ited to intermittent use during times of i n c re a s e d p h y s i c al s t r e s s o r prophylactic use at work; and (3) maxim um continuous dura tion, up to three weeks unless patient is status pos tfusion. Subp. 4. Active treatment m odalities. Active treatment modalities must be used as set forth in item s A to D. Use of active treatment modalities may extend past the 12-week limitation on passive treatment modalities, so long as the maxim um duration for the active modality is not exc eed ed. A. Education must teach the patient about pertinent anato m y and physiology as it relates to spinal function for the purpose of injury prevention . Education includes training on posture, biomechanics, and relaxation. The m aximum number of treatm ents is three visits, which includes an initial education and training session, and two fo llow-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 arm s, use of optimum biomechanics in performing job tasks, and app ropriate pacing of activities. Methods include didactic sessions, demonstrations, exercises, and sim ulated work task s. The maxim um num ber of treatments is three visits. C. W ork site analysis and modification must examine the patien t's w ork s tatio n, to ols, and job duties. Recom m endations are made for the alteration of the work station, selection of alternate tools, modification of job duties, and provision of adaptive equ ipm ent. The m aximum number of TP-25

treatm ents is three visits. D. Exercise, which is important to the success of an initial nonsurgical treatment program and a return to norm al activity, must include active patient participation in activities designed to increase flexibility, strength, endurance, or muscle relaxation. Exercise m ust, at least in part, be specifically aimed at the mu sculature of the cervical spine. W hile aerobic exercise and extre m ity strengthening may be performed as a djun ctive treatm ent, it must not be the prim ary foc us o f the exercise prog ram . Ex ercises m ust be evaluated to determine if the desired goals are being attained. Strength, flexibility, and endurance must be objectively measured. W hile the provider may objectively m easure 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 m onthly there after. Subitems (1) and (2) govern supervised and unsupervised exercise, except for computerized exercise program s and health clubs, which are governe d by pa rt 522 1.66 00. (1) Supervis ed exercise. One goal of an exercise program must be to teach the patient how to maintain and m axim ize any gains experienced from exercise. Self-managem ent of the condition m ust be pro m oted : (a) maxim um treatm ent frequency, three times per week for three weeks, decreas ing in frequency thereafter; and (b) m axim um dura tion, 12 wee ks . (2) Unsupervised exercise must be provided in the least inte nsive setting app ropriate to the goals of the exercise program, and may supplement or follow the period of supervised exe rcise : (a) maxim um treatment frequency, up to three visits for instruction and monitoring; and (b) there is no lim it on the duration or frequen cy of exercise at hom e. Subp. 5. Therapeutic injections. Injection modalities are indicated as set forth in item s A to C. Use of injections may extend past the 12-week lim it on passive treatment modalities, so long as the m axim um treatment for injections is not exc eed ed. A. Therapeutic injections include trigger points injections, facet joint injections, facet nerve bl ocks, symp athetic nerve bl oc k s,

5221.6205

STATE OF MINNESOTA

Treatment Parameter Rules

epidurals, nerve root blocks, and peripheral nerve blocks. Therapeutic injections can only be given in conjunction with active treatment modalities directed to the sam e anatomical site. (1) Trigger point injection s: (a) tim e for treatment response, with in 30 m inutes ; (b) m aximum treatm ent fre quency, once per week if a positive response to the first injection at that site. If subsequent injections a t t h a t s i te d e m o n s t r a te diminishing control of symptoms or fail to facilitate objective functional gains, then trigger point injections should be redirected to other areas or discon tinued . Only three injections are reimbursable per patient visit; and (c) m a x i m u m t re a tm e n t , f o ur injections to any on e site. (2) Facet joint injections or facet nerve blocks: (a) tim e for treatm ent response, with in one wee k; (b) m aximum treatm ent fre quency, once every two weeks if a positive response to the first injection or block. If subsequent injections or blocks dem onstrate dim inishing control of sym ptom s or fail to facilitate objective functional gains, then injectio ns or b locks should be discontinued. Only three injections or block s are reim bursable per patient visit; and (c) ma x i m u m t re a t m e n t, three injections or bloc ks to any one site. (3) Ne rve ro ot bloc ks: (a) tim e for treatm ent response, with in one wee k; (b) maxim um treatm ent fre quency, can repeat injection no sooner than two weeks after the previous injection if a pos itive resp ons e to the first inje ctio n. N o more than three block s are reim bursable per patient visit; and (c) maxim um treatm ent, two bloc ks to any on e site. (4) Epidural injections: (a) tim e for treatm ent response, with in one wee k; (b) m aximum treatm ent fre quency, once every two weeks if a positive response to the first injection. If subsequent injections demonstrate dim inishing control of symptoms or TP-26

fail to facilitate objective functional gains, then injections should be discontinued. Only one injectio n is reim bursable per patien t visit; and (c) maxi m u m treatm ent, three injections. B. Permanent lytic or sclerosing injections, including radio frequency denervation of the fa cet joints. These injections can only be given in conjunction with active treatment modalities directed to the same ana tom ical site: (1) tim e for treatment response, within one wee k; (2) maxim um treatment frequency, may repeat once for any site; and (3) maxim um duration, two injections to any on e site. C. Prolotherapy and botulinum toxin injections are not in dicated in the treatment of neck prob lem s an d are not reimburs able. Subp. 6. Su rgery, including decomp ression procedures and arthrodesis. Surgery m ay only be performed if it m eets th e specific parameters of sub parts 11 to 14 and pa rt 522 1.65 00. Th e he alth care provider m ust provide prior notification for nonemergency inpatient surgery according to part 522 1.60 50, subp art 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 maxim um treatm ent 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 dorsal column stimulator or m orphine pum p; or (2) 12 w eek s follow ing arthrod esis. B. Repeat surgery must also meet the param eters of subparts 11 to 14 and part 5221.6500 and is not indicated unless the need for the repeat surgery is confirmed by a second opinion obtain ed before surgery, if requ este d by the insurer. C. The following surgical therapies have very limited application and require a second opinion which confirms that the treatment is indicated and with in the parameters listed, and a personality or psychosocial evaluation indicates that the patien t is lik ely to benefit from the treatm ent. (1) Dorsal column stim ulator is indicated for a patient who has neuropath ic pain,

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STATE OF MINNESOTA

Treatment Parameter Rules

is not a candidate for any other invasive therapy, and has had a favorable resp ons e to a trial screening period. (2) Morphine pum p is indicated for a patient who has som atic pa in, is not a candidate for any other invasive therapy, and has had a fav orable respon se to a trial screen ing pe riod. Subp. 7. Chronic managem ent. Ch ronic managem ent of neck disorders must be provided acc ording to the para m eters of pa rt 522 1.66 00. Subp. 8. Du rable m edical equipm ent. Durable medical equipment is indicated only as specified in item s A to D. Th e health care provider must provide prior notificatio n as required in items B an d C acc ording to part 52 21.6 050 , subpart 9 . A. Cervical collars, braces, or supports and hom e cervical traction devices may be indicated within the parameters of subpart 3, item s F and K. B. For patien ts us ing electrical stim ulation at home, the device and any required s u p p l ie s are ind icated within th e param eters of subpart 3, item E. Prior notification m ust be given for purchase of the device or for use longer than one month. The insurer may provide equipment if it is comparable to that pres cribed by the hea lth care pro vider. C. Exercise equipment for home use, inc lu d i n g b i c yc l e s , tre a d mi ll s, and stairclimbers, are indicated only within the con text of a program or plan of an approved chronic managem ent program. This equ ipm ent is n ot indicated during initial nonoperative ca re or d uring reevaluation and surgical therapy. Prior notifica tion must be given to the insurer before purchase of the home exercise equ ipm ent. 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 prem ises with the prescribed equ ipm ent, the insurer may mandate the use of that facility instead of authorizing purc has e of e quipm ent fo r hom e us e. (1) Indica tio n s : the p atient is d e c o n d i ti o n e d and r e q u ir e s r e c o n d i t io n i n g w h i c h c a n b e accomplished only with the use of the prescribed exercise equipment. The hea lth care provider must document specific reasons why the exercise equipment is necessa ry and cannot be replaced with oth er ac tivities. (2) Requirements: the use of the

equipment must have specific goals and there must be a specific set of pres cribed ac tivities. D. The following durable m edical equipm ent is not indicated for home use for neck pain con ditions: (1) whirlpools, Jacuzzis, hot tubs, and special bath or shower attachments; or (2) beds, waterbeds, mattresses, chairs, recliners, and lou nge rs. Subp. 9. Evaluation of treatment by health care prov ider. The health care provider must evaluate at each visit whether the treatm ent is m edically necessary, and shall evaluate whether initial nonsurg ical mana gem ent is effective according to items A to C. No later than the time for treatment response established for the specific modality as specified in sub parts 3, 4, and 5, the health care provider must evaluate whether the passive, active, injection, or medication treatment modality has resulted in progress ive improvement as specified in items A to C: A. the employee's subjective complaints of pain or disability are pro gressively improving, as evidenced by documentation in the m edical record of decreased distribution, frequency, or intensity of sym ptom s; B. the objective clinical findings are progressively im proving, as evidenced by documentation in the medical record of resol uti on or objectively m easure d improvement in physical sign s of injury; and C. the employee's functional status, especially vocational activity, is progressively improving, as evidenced by documentation in the m edical record, or succes sive repo rts of work ability, of less restrictive limitations o n ac tivity. If there is not progressive im provem ent in at least two items of items A to C, the mod ality must be discontinued or significantly m odified or the provider must reconsider the diagnosis. The evaluation of the effectiveness of the treatment m oda lity can be delegated to an allied hea lth professional working under the direction of the treating health care provider bu t re m ain s th e u ltim ate respon sibility of the treating health care prov ider. Subp. 10. Scheduled and nonscheduled medication. Prescription of controlled substance medications scheduled under Minnesota Statutes, section 152.02, including, without limitation, narcotics, is indicated only for the treatment of

TP-27

5221.6205

STATE OF MINNESOTA

Treatment Parameter Rules The purpose of surgical eva luation is to determine whether surgery is indicate d 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 m ana gem ent is ind icated . (1) Surgical evaluation if indicated may begin as soon as eight weeks after, but must beg in no later than 12 weeks after, beginning initial nonsurgical m ana gem ent. An initia l recom mendation or decision against surgery does no t preclude surgery at a later da te. (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 param eters of part 522 1.61 00, subp art 1. (3) Surgical evaluatio n m ay also include diagnostic blocks and injections. These block s an d injec tions are only indicated if their use is consistent with the param eters of su bpa rt 1, item H. (4) Surgical evaluation may also include pers ona lity or psychosocial evaluation, consistent with the parameters of sub part 1 , item G. (5) Consultation with other health care providers m ay be a ppro priate as part of the surgical evaluation. The need for consultation and the choice of consultant will be determ ined by the f in d i n g s o n m e d i c a l i m a g i n g, diagnostic analgesic blocks and injections, if performed, and the patient's ongoing subjective com plaints and physical findings. (6) The only surgical procedure indicated for patients w ith regional neck p ain only is cervical arthrodesis, with or without instrumentation, which must meet the param eters of subpart 6. For patien ts with failed surgery, dorsal column stimulators or m orphine pumps may be indicated consistent with the para m eters of su bpa rt 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 pro posed surgery, it should be performed as expeditiously as possible consistent with sound m edical practice, and consistent with any requirements of part 5221.6050, subpart 9, for prior

severe acute pain. These medications are not indicated in the treatment of patients with regional nec k pain after the first two wee ks. Patients with radicular pain m ay require longer periods o f treatm ent. The health care provider must document the ration ale for the use of any scheduled medication. Treatment with nonnarcotic medication may be app ropriate during any phase of treatment and inte rm itten tly after all other treatment has been discontinued. The prescribing health care provider mus t determ ine that ongoing m edication is effective treatment for the patient's condition and the m ost c ost-e ffec tive reg imen is u sed . Subp. 11. Spe cific treatm ent p aram eters for regional neck pain. A. Initial non surgical treatm ent m ust be the first phase of tre atm ent for all patien ts with regional neck pain under sub part 1, item A, sub item (1). (1) The active, passive, injection, durable medical equipment, and medication treatm ent m odalities and p rocedure s in subpa rts 3, 4, 5, 8, and 10, may be used in sequence or simultaneously during the period of initial nonsurgical managem ent depending o n the severity of the con dition. (2) The only therapeutic injections indicated for pa tients w ith regional neck pain a re trigger po int injections, facet joint injections, facet nerve blocks, and epidural blocks, and their use m ust m eet the parameters of sub part 5 . (3) After the first we ek of trea tm ent, initial nonsurgical treatment must at all times conta in active treatm ent m odalities according to the param eters of subpa rt 4. (4) Initial non surgical treatment must be provided in the least intensive setting consistent with quality health care prac tices. (5) Except as otherwise provided in s u b p a r t 3 , p as s i v e t re a t m e n t 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 in itial nonsurgical mana gem ent, and if the patient's condition prevents the resumption of the regular activities of da ily life including regular vocational activities.

TP-28

5221.6205

STATE OF MINNESOTA

Treatment Parameter Rules

notification of the insurer or sec ond opinions. (b) If surgery is n ot indicate d or if the patient does not wish to proceed with surgical therapy, then the patient is a candidate fo r chronic m ana gem ent. C. If the patient continues with symptom s 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 prev ents the resumption of the regular activities of daily life including regular vocational activities, then the patient may be a candidate for chronic management acc ording to part 52 21.6 600 . Subp. 12. Spe cific treatm ent p aram eters for radicular pain, with or without regional neck pain, with no or static neurologic deficits. A. Initial nonsurgical treatm ent is a ppro priate for all patients with radicular pain, with or without regional neck pain, w ith no or static neurologic deficits under subpart 1, item A, subitem (2), and must be the first phase of treatm ent. It m ust be pro vided within the param eters 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 w ith radicular pain on ly. If there is a component of regional neck pain, the rapeutic facet joint injections, facet nerve block s, and trigge r point injections m ay also be ind icated . 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 param eters of subpa rt 11, item B, with the following modifications: the only surgical pro cedures indic ated for p a tients w i th r a di c u la r p a in a re decom pression of a cervical nerve root which must m eet the parameters of subpa rt 6 and part 5221.6500, subpart 2, item B, and cervical arthrodesis, with or without instrum enta tion. Fo r patien ts with failed surgery, dorsal column stimulators or morphine pum ps m ay be indicated con sistent with s ubp art 6, item C. 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 d aily life including regular vocational activities, then the patient m ay be a candidate for chronic managem ent. Any course or program of chronic management for patien ts with radicular pain, with or without regional neck pain, w ith static neurologic changes must m eet all of the param eters of pa rt 522 1.66 00. Subp. 13. Spe cific treatm ent p aram eters for radicular pain, with or without regional neck pain, with progressive neuro logic changes. A. Patients with radicular pain, with or without regional neck pain, with progressive neurologic deficits may require imm ediate or emergency evaluation at any time during the course of the ir 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 nonsurgical treatments. Su rgery, if indicated, may be performed at any time during the course of treatment. Surgical evaluation and surgery shall be provided within the parameters of subpa rt 11, item B, with the following modifications: (1) surgical evaluation and surgical therapy may begin at any time; and (2) the only surgical procedures indicated for patients with radicular pain are decompression of a cervical nerve root which m ust m eet the parameters of subpa rt 6 and part 5221.6500, su bpart 2, item B, or cervical arthrodes is, with or without instrumentation. For patients with faile d back s urgery, dorsal colum n stimulators or morphine pumps may be indicated consistent with the parameters of subpart 6, item C. B. If the he alth ca re provide r dec ides to proceed with a course of no nsurgical care for a patien t with rad icular p ain 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 d aily

TP-29

5221.6205

STATE OF MINNESOTA

Treatment Parameter Rules

life including regular vocational activities, then the patient may be a candidate for chronic m anagem ent. An y course or program of chronic management for patien ts with radicular pain, w ith or without regional neck pain, with progressive neurologic changes at first presentation must meet all of the parameters of part 522 1.66 00. Subp. 14. Spe cific treatm ent p aram eters for mye lopathy. A. Patients with m yelopathy m ay require emergency surgical evaluation at any tim e during the course of their overall trea tm ent. T he decision to proceed with surgical evaluation is mad e by the health care provider based on the type of ne urologic changes observed, the severity of the changes, the rate of progression of the changes, and the response to any nonsurgical treatm ents. Surgery, if indicated, m ay be perform ed at any tim e during the course of treatment. Surgical evaluation and surgery shall be provided with in the param eters of subpa rt 11, item B, with the fo llowing m odifica tions: (1) surgical evaluation and surgical therapy may begin at any time; and (2) the only surgical procedures indicated for patien ts with m yelopa thy are anterior or posterior decompression of the spinal cord, or c ervical arthrodesis with or without instrumentation. For patients with faile d back s urgery, dorsal column stimulators or morphine pumps may be indicated consistent with the param eters of subpart 6, item C. B. If the hea lth care pro vider d ecides to proceed with a course of nonsurgical care for a patient with myelopathy, it must follow the param eters of su bpa rt 12, item A. C. If the patient continues with symptoms and objective physical fin dings after surgical therapy has been rendered or the patient refuses surgical therapy or the patient was not a can didate 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 managem ent. Any course or program of chronic management for patien ts with myelopathy must meet all of the param eters of pa rt 522 1.66 00. STAT AUTH : MS s 176.103; 176.83 HIST: 19 SR 1412

522 1.62 10 T HO RAC IC B ACK PAIN . Subpa rt 1. Diagnostic procedures for treatment of th oracic back inju ry. A health care provider shall determine the nature of the condition before initiating treatm ent. A. An appropriate history and physical examination must be performed and documented. Based on the history and physical exam ination the health care provider must assign the patient at each visit to the consistency appropriate clinical category according to subitems (1) to (4). The diagnosis must be documented in the medical reco rd. For the purposes of subitems (2) and (3 ), "radicular pain" means pain radiating in a dermatom al distribution around the chest or abdom en. This part does not apply to fractures of the tho racic spine or thoracic back pain due to an infectious, imm unologic, metabolic, endocrine, neu rolog ic, visce ral, o r neo plastic disease proc ess . (1) Regional thoracic back pain includes the diagnoses of thoracic strain, s p r a in , m y o f a s c ia l s yn d r o m e , musculoligamentous injury, soft tissue inju ry, and any other diagnosis for pain believed to originate in the discs, ligaments, muscles, or other soft tissues of the thoracic spine and which effects the thoracic region, including, but not limited to, 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 92 6.12 . (2) Radicular pain, with or without regional thoracic back pain, includes the diagnoses of thoracic ra diculopathy, radiculitis, or neuritis; displacement or herniation of interve rtebral disc with radiculopathy, radiculitis, or neuritis; spinal stenosis with radiculopath y, radiculitis, or neuritis; and any other diagnoses for pain believe d to originate with irritation of a nerve root in the tho racic spine, including, but not limited to, the 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 com pres sive m yelopa thy, with or without radicular pain, is a condition characterized by weakness and spa sticity in one or bo th legs and

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B.

C.

D.

E.

F.

associated with any of the following: exaggerated reflexes, an extensor plantar res ponse, bow el or bladder dysfunction, sensory ataxia, or bilateral sen sory change s. Laboratory tests are not indicated in the evaluation of a patient with regional tho racic back pain, or radicular pain, except whe n a patient's history, age, or e x a m i n a t io n s u g g e s t s in f e c t io n , m e t a b o l ic - e n d o c r in o log ic d i s o r d e r s , tumorous c o n d i ti o n s , s ys t e m ic musculoskeletal disorders, such as rhe um ato id a rth ritis or a nk ylos ing spondylitis, or side effects of medications. Laboratory tests may be ordered at any tim e the health care provider suspects any of these cond itions, but the health care provider m ust justify the need for the tes ts ordered with clear documentation of the indications. Laboratory tests may also be ordered as part of a preope rative evaluation. Medical im aging evaluatio n of the thoracic spine must be based on the findings of the history and physical examination and cannot be ordered prior to the health care pro vider's clinical evaluation of the patien t. Medical imaging may not be performed as a routine procedu re and m ust c om ply with all of the standards in part 5221.6100, subpa rt 1. The health care provider must document the appropriate indicatio ns for any m edical im aging studies obtained. EMG and nerve c onduction studies are alw ays inappropriate for reg ional thoracic back pain and rad icular pain under item A, sub item s (1) to (3). The use of the following procedures or tests is not indicated for the diagnosis of any of the clinical catego ries in item A: (1) surface electromyography or surface para spinal EM G; (2) therm ogra phy; (3) plethysm ogra phy; (4) electronic X-ray analysis of plain radiograp hs; (5) diagnostic ultrasound of the spine; or (6) som atosenso ry evoked potentia ls (SSEP) and m oto r evok ed poten tials (MEP). Com puterized range of motion or stre ngth measuring tests are not reim bursable during the period of initial nonsurgical care, but may be reimbursable during a period of chronic management when used in conjunction with a computerized exercise program, work hardening program, or work conditioning prog ram . During the period of TP-31

initial nonoperative care computerized rang e of m otion o r stren gth testing can be performed but must be done in conjunction with and shall not be reim bursed separately from an office visit, chiropractic evaluation or treatmen t, or physical or occupational thera py eva luation or trea tm ent. G. Personality or psychological evaluations may be a useful tool for evaluating patien ts who continue to have problems de spite app ropriate care. The treating health care provider may perform this evaluation or may refer the patient for con sultation with another hea lth ca re provide r 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 w ith recovery from the injury. Since more than one of these psychological conditions may be present in a given case, the hea lth care provider perform ing the evaluatio n m ust con sider 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 poss ible treatm ent, are psychological factors, such as those listed in sub item s (1) to (6), like ly to interfere with the potential benefit of the surgery? H. Diagnostic analgesic blocks or injection studies include fac et joint inje ction, facet nerve block, epidural differential spinal block, ne rve block , and nerve roo t block . (1) These procedu res are use d to loc alize the source of p ain prior to surgery and to diagnose conditions which fail to respon d to initial nonop erative care . (2) These blocks and injections are invasive and when done as diagnostic procedures only are not indicated unless noninvasive proced ures have failed to establish the diag nos is. (3) Selection of patients, choice of procedure, and localization of the level of injection should be determined by documented clinical findings indicating possible patho logic conditions and the

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sou rce of pa in sym ptom s. (4) These blocks and injections can also be used as therapeutic modalities and as such are subject to the guidelines of sub part 5 . I. Functional capacity assessment or evaluation is a comprehensive and objective ass ess m ent of a pa tient's ability to perform work tasks. The components of a fun ctio nal capacity assessment or evaluation include, but are not limited to, neuromusculoskeletal screening, tests of m anual material handling, assessment of functional m obility, and measurement of postural tolerance. A fun ctio nal capac ity a s s e s s m e n t o r e v a lu a t io n i s a n individualized testing process and the component tests and measurem ents are determined by the patient's condition and the requested information. Functional cap acity asses sm ents and eva luations are performed to determ ine an d rep ort a patient's physical capacities in gen eral or to determine work tolerance for a specific job, task , or wo rk activity. (1) Functional capacity assessment or evaluation is not reim bursable during the period of initial nonoperative care. (2) Functional capacity assessment or evaluation is reimbursable in either of the fo llowing circum stan ces : (a) permanent activity restrictions and capab ilities m ust be identified; or (b) there is a question about the patient's ability to do a specific job. J. Consultations with other health care providers can be initiated at any tim e by the treating health care pro vider consiste nt w ith stan dard m edical practice. Subp. 2. General treatment parameters for thoracic back pain. A. All medical care for thoracic back pain, app ropriately assigned to a category of subpa rt 1, item A, is determined by the diagnosis and clinical category in subpa rt 1, item A, to which the patient has been assigned. General parameters for treatment m odalities are set forth in sub parts 3 to 10. Specific treatment param eters for each clinical cate gory are set fo rth in su bpa rts 11 to 13, as fo llows: (1) subpa rt 11 governs reg ional thoracic bac k pain; (2) subpa rt 12 governs radicular pain; and (3) sub part 1 3 go vern s m yelopa thy. The hea lth 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 inform ation o bta ined from consultations with other health care providers. W hen the clinical category is changed the treatment plan must be appropriately modified to reflect the new clinical category. However, a change of clinical categ ory does not in its elf allow the hea lth care provider to continue a therapy or treatm ent m odality past the maximum duration spe cified in item s C to F, or to repeat a therapy or treatm ent previously prov ided for the sam e injury. B. In gen eral, a course of treatment is divided into thre e ph ase s. (1) First, all patie nts with thoracic back problems, except patients w ith myelopathy und er su bpa rt 1, item A, subitem (3), must be given initial nonoperative care which may include acti ve a n d p a s s iv e t re a t m e n t modalities, injections, durable medical equ ipm ent, and medications. These m odalities and parameters are described in subparts 3, 4, 5, 8, and 10. The period of initial nonsurgical treatment beg ins with the first clinical passive, active, injection, durable medical equipment, or medication m oda lity initiated . Initia l nonsurgical treatment m ust result in progressive improvement as specified in subpart 9. (2) Second, for patients with persistent s y m p t o m s , i n i t i a l n o n s u r g ic a l managem ent is followed by a period of surgical evaluation. This evaluation should be com pleted in a tim ely m anner. Surgery, if ind icated , sh ould be performed as expeditiously as possible con sistent with sound medical practice and subparts 6 and 11 to 13, and part 5221.6500. The treating hea lth care provider m ay do the evaluation, if it is within th e provider's scope of practice, or may refer the em ployee to a cons ultant. (a) Patients with myelopathy may r e q u i r e i m m e d i a te s u r g ic a l the rapy. (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 nons urgical care. (c) S u r gery must f o ll ow th e param eters in subparts 6 and 11

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to 13, and part 5221 .650 0. (d) A decision against s urgery at this tim e does not preclude a decision for surgery made at a later da te in light of new c linical inform ation. (3) Third, for those patients who are not candidates for or refuse surgical the rapy, or who do not have com plete resolution of the ir sym ptom s with su rg er y, a p e r io d o f c h ro n ic managem ent may be indicated. Chronic m anagem ent m odalities are described in part 5221.6600, and may a l s o i n c lu d e d u r a b le m e d i c a l equ ipm ent as de scribed in sub part 8 . C. A treating health care provider may refer the employee for a consultation at any tim e 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 mod alities in item C to I are initiated. Th ere are no lim itations on the use of passive treatment modalities by the em ployee at hom e. B. (1) An add itional 12 visits for the use of passive treatment modalities over an additional 12 months may be provided if all of the fo llowing app ly: (a) the em ployee is released to work or is permanently totally disabled a n d the ad ditio na l pa ss ive t r e at m e n t m u s t r e s u l t i n progressive improvement in, or maintenance of, fun ctio nal status achieved during the initial 12 wee ks of pa ssive care ; (b) the treatment must not be given on a reg ularly sched uled bas is; (c) the health care provider must document in the medical record a plan to encourage the em ploye e's independence and decre ased reliance on health care providers; (d) managem ent of the em ploye e's condition m ust include active treatment m odalities during this period; (e) the additional 12 visits for passive treatmen t must not delay the required surgical or chronic pain ev alu atio n requ ired b y this chapter; and (f) passive care is inapp ropriate while the em ployee has chronic pain TP-33

syndrom e. (2) Except as otherwis e provided in part 5221.6050, subpart 8, treatment m ay continue beyond the additional 12 visits only after prior approval by the insurer, com m issioner, or compensation judge based on documentation in the medical record of the effectiveness of f u r th e r p a s s i v e t r e a t m e n t i n m aintaining em ployab ility; if the em plo yee is pe rm an en tly totally disabled, or if upon retirement the employee is eligible for ongoing medical benefits for the work injury, treatment m ay continue beyond the additional 12 visits only after prior approval by the insurer, com m issioner, or compensation judge based on documentation in the medical record of the effectiveness of further passive treatment in maintaining functional status. C. Adjustment or m anipulation of joints includes chiroprac tic and osteopathic adju stm ents or m anipulations: (1) tim e for treatment response, three to five trea tm ents ; (2) maxim um treatm ent fre que ncy, up to five times per week for the first one to two weeks decreasing in frequency thereafter; and (3) maxim um treatment duration, 12 wee ks. D. Thermal treatment includes all superficial and deep heating modalities and cooling modalities. Superficial thermal m odalities include hot packs , hot soaks, hot water bottles, hydrocollators, heating pads, ice packs, cold soaks, infrared, whirlpo ol, and fluidothe rapy. Deep therm al modalities include diathermy, ultrasound, and m icrow ave. (1) Treatm ent given in a clinical setting: (a) tim e for treatment response, two to four treatm ents ; (b) maxim um treatment frequency, up to five tim es per week for the first one to th ree weeks decreasing in frequency thereafter; and (c) maxim um treatment duration, 12 weeks of treatment in a clinical setting but only if g iven in con junc tion with other thera pies. (2) H om e use of therm al m odalitie s m ay be prescribed at any time during the course of treatment. Home use m ay only involve hot packs, hot soaks, hot water bottles, hydrocollators, heating pads, ice packs, and cold soaks which

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Treatment Parameter Rules edu cation and training, one session; and (b) a patient may use the mechanical traction device for one mon th, at which time effectiveness of the treatment must be reevaluated by the health care provider before continuing home use of the device. Acupuncture treatm ents. Endorphin-mediated analgesic therapy i nclu d e s c l a s s ic a c u p u n cture and acu pres sure: (1) tim e for treatm ent re spo nse , three to five sessions; (2) maxim um treatm ent fre que ncy, up to three times per week for one to three weeks decreasing in frequency thereafter; and (3) m aximum treatment duration, 12 wee ks. Manual therapy includes soft tissue and joint mob ilization, therapeutic massage, and m anu al traction: (1) tim e for treatment resp ons e, three to five trea tm ents ; (2) maxim um treatm ent fre que ncy, up to five times per wee k fo r the firs t one to two weeks decreasing in frequency thereafter; and (3) maxim um treatment duration, 12 wee ks. Ph oresis includes iontophoresis and pho nop hore sis: (1) tim e for treatm ent re spo nse , three to five se ssions; (2) maxim um treatm ent fre que ncy, up to three times p er week for the first one to three weeks decreasing in frequency thereafter; and (3) maxim um treatment duration, 12 wee ks. Bedres t. Prolonge d res triction of ac tivity and im m obilizatio n are detrim ental to a patient's recovery. Bedrest should not be pres cribed for m ore th an s even da ys. Spinal braces and other movem ent-restricting appliances. Bracing required for longer than two weeks must be accompanied b y a c t iv e m u s c l e s t r e ng t h e n i n g e x e r c is e t o a vo id dec ond itioning and p rolonged disab ility: (1) tim e for treatment response, three days; (2) maxim um treatment frequency, limited to interm ittent use du ring times of in c r e a s e d p h y s ic a l s tr e s s o r prophylactic use at work; and (3) maxim um continuous duration, three weeks unless patient is status

can be applied by the patient without hea lth 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 m uscle stimulation includes galvanic stim ulation , TEN S, in terferentia l, and m icroc urrent techniques . (1) Treatm ent given in a clinical setting: (a) tim e for treatment response, two to four treatm ents ; (b) maxim um treatment frequency, up to five times per week for the first one to three weeks decreasing in frequency thereafter; and (c) maxim um treatment duration, 12 weeks of trea tm ent in a clinical setting but only if g iven in con junc tion with other thera pies. (2) H om e use of an electrical stimulation device m ay be presc ribed at any tim e during a course of treatment. Initial use of an electrical stimulation device must be in a supervised setting in order to ensure proper electrode placem ent and patient e duc ation: (a) maxim um time for patient education and training, up to three sessions; and (b) patient m ay 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. Me cha nical traction: (1) Treatm ent given in a clinical setting: (a) tim e for treatment response, three treatm ents ; (b) maxim um treatm ent fre quency, up to three times per week for the first one to three weeks decreasing in frequency thereafter; and (c) maxim um treatment duration, 12 weeks in a clinical setting but only if used in conjunction with other thera pies. (2) H om e 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 treatm ent. Initial use of a mechanical traction device must be in a supervised setting in order to ensure prop er pa tient ed uca tion: (a) maxim um tim e for patient TP-34

G.

H.

I.

J.

K.

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pos tfusion. Subp. 4. Active treatment m odalities. Active treatment modalities must be used as set forth in items A to D. Use of ac tive treatment modalities may extend past the 12-week limit on passive treatment modalities, so long as the maxim um durations for the active treatment m oda lities are n ot excee ded . A. Education must teach the patient about pertinent anato m y and physiology as it relates to spinal function for the purpose of injury prevention . Education includes training on posture, biomechanics, and relaxatio n. The m aximum number of treatm ents is three visits, which includes an initial education and training session, and two fo llow-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, back, and arm s, use of optimum biomechanics in performing job tasks, and appropriate pacing of activities. Methods include didactic sessions, demonstrations, exercises, and sim ulated work task s. The maxim um number of treatments is three visits. C. W ork site analysis and modification must examine the patient's work station, tools, and job duties. Recom m endations are made for the alteration of the work station, selection of alternate tools, modification of job duties, and provision of adaptive equ ipm ent. The m aximum number of treatm ents is three visits. D. Exercise, which is im porta nt 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 m ust, at least in part, be specifically aimed at the m usculature of the tho racic spine . W hile aerobic exercise and extre m ity strengthening may be performed as adjunctive treatment this shall not be the prim ary foc us o f the e xercise prog ram . Exercises shall be evaluated to determine if the desired goals are being attained. Strength, flexibility, and endurance shall be objectively measured. W hile the pro vider m ay obje ctively m easure 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 m onthly thereafter. Subitems (1) and (2) TP-35

govern supervised and unsupervised exercise, except for computerized exercise programs and hea lth clubs, which are governe d by pa rt 522 1.66 00. (1) Supervised exercise. One goal o f an exercise program must be to teach the patient how to maintain and m axim ize any gains experienced from exercise. Self-managem ent of the condition m ust be pro m oted : (a) m aximum treatm ent fre quency, three times per week for three weeks and sho uld de crease with time thereafter; and (b) m axim um dura tion, 12 wee ks . (2) Unsupervised exercise must be provided in the least intensive setting app ropriate to the goals of the exercise program and may supplement or follow the period of su perv ised exe rcise : (a) m aximum treatm ent fre quency, one to th ree visits for instructio n and monitoring; and (b) there is no limit on the duration and frequency of exercise at hom e. Subp. 5. Therapeutic injections. Injection modalities are indicated as set forth in item s A to C. Use of injections may extend past the 12-week lim it on passive treatment m odalities, so long as the maxim um treatment for injections is not exc eed ed. A. Therapeutic injections include trigge r points injections, facet joint injections, facet nerve bl ocks, sympatheti c nerve b lo c k s, epidurals, nerve roo t block s, and peripheral nerve block s. T herapeutic injections can only be given in conjunc tion with active treatment m odalities directed to the same ana tom ical site. (1) Trigger point injection s: (a) tim e for treatment response, with in 30 m inutes ; (b) m axim um treatm ent fre quency, once per week if a positive response to the first injection at that site. If subsequent injections a t t h a t s i te d e m o n s t r a t e diminishing control of symptom s or fail to facilitate objective functional gains, then trigger point injections should be redirected to other areas or discontinued. No m ore than three injectio n s are reim bursable per patient visit; and (c) m a x i m u m t r e atm ent , four injections to any on e site. (2) Facet joint injections or facet nerve blocks:

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(a) tim e for treatm ent response, with in one wee k; (b) maxim um treatm ent frequency, once every two weeks if a positive response to the first injection or block. If subsequent injections or blocks dem onstrate dim inishing control of sym ptom s or fail to facilitate objective functional gains, then injectio ns or b locks should be discontinued. Only three injections or block s are reim bursable per patient visit; and (c) ma x i m u m t re a t m e n t, three injections or bloc ks to any one site. (3) Ne rve ro ot bloc ks: (a) tim e for treatm ent response, with in one wee k; (b) maxim um treatment frequency, can repeat injection two weeks after the previous injection if a positive response to the first block. O n l y t h r e e i n j e c t i o n s a re reim bursable per patien t visit; and (c) maxim um treatm ent, two bloc ks to any on e site. (4) Epidural injections: (a) tim e for treatment res ponse, w ithin one wee k; (b) maxim um treatm ent fre quency, once every two weeks if a positive response to the first injection. If subsequent injections demonstrate dim inishing control of symptoms or fail to facilitate objective functional gains, then injections should be discontinued. Only one injectio n is reim bursable per patien t visit; and (c) m ax im um t re a t m e n t, thre e 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 sam e ana tom ical site: (1) tim e for treatment response, within one wee k; (2) optim um treatment frequency, may repeat once for any site; and (3) maxim um duration, two injections to any on e site. C. Prolotherapy and botulinum toxin injections are not ind icated in the treatm ent o f thoracic back problems and are not reim burs able. Subp. 6. Su rgery, includ ing decompression procedures. Surgery m ay only be perform ed if it

m eets the spec ific para m eters of su bpa rts 11 to 13 and part 5221.6500. The health care provider must provide prior notification of nonemergency inpatient surgery according to part 5221.6050, sub part 9 . A. In ord er 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 m axim um treatm ent duration with passive treatm ent modalities in a clinical setting from the initiation of the first passive m oda lity used, except bedrest or bracing, is as follows : (1) eight weeks following decompression or im planta tion of a dorsal column stimulator or m orphine pum p; or (2) 12 w eek s follow ing arthrod esis. 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. The surgical therapies in subitems (1) and (2) have very limited application and require a second op inion which confirms that the treatm ent is indicate d and with in the parameters listed, and a personality or psychosocial evaluatio n which indicates that the patient is likely to ben efit from the treatm ent. (1) Dorsal column stimulator is indicated for a patient who has neuropathic pain, and is not a candidate for any other invasive therapy, and has had a favorable resp ons e to a trial screening period. (2) Morphine pum p is indicated for a patient who has som atic pain, and is not a candidate for any other invasive the rapy, and has had a favorable respon se to a trial screen ing pe riod. Subp. 7. Chro nic m anag em ent. Ch ronic managem ent of thoracic back pain must be provided according to the param eters of part 522 1.66 00. Subp. 8. Durab le med ical equipm ent. Durable medical equipment is indicated only in certain specific situations, as specified in items A to D. The health care provider must provide the insurer with prior notification as required by items B and C, according to part 5221.6050, subpart 9. A. Braces or sup ports m ay be indicate d within the param eters of su bpa rt 3, item K.

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B. For patients using electrical stimulation or mechanical traction devices at home, the device and any required supplies are indicated with in the parameters of subpart 3, items E a nd F. Prior notification of the insurer is required for purchase of the device or for use longer than one month. The insurer m ay provide equipm ent if it is com parable to that prescribed by the hea lth care pro vider. C. Exercise equipment for home use, inc lu d i n g b i c yc l e s , tre a d mi l ls, and sta irclim bers, are indicated only within the context of a program or plan of an approved chronic managem ent program. This equ ipm ent is not indicated during initial nonope rative care or du rin g reevaluation and surgical therapy. Prior notification of the insurer is required for the purchase of ho m e ex ercise eq uipm ent. The insurer may decide wh ich brand of a prescribed type of exercise equipm ent is provided to the patien t. If the employer has an appropriate exercise fac ility on its premises with the p rescribed eq uipm ent, the insurer may mandate the use of that facility instead of authorizing purchase of equ ipm ent fo r hom e us e. (1) In d ica tio n s : the pa tient is d e c o n d i ti o n e d and requires r e c o n d it io n i n g w h ic h c a n b e accomplished only with the use of the prescribed exercise equipment. The hea lth care provider must document specific reasons why the exercise equipment is necessary and cannot be replaced with oth er ac tivities. (2) Requirements: the use of the equipment mus t have specific goals and there must be a specific set of pres cribed ac tivities. D. The following durable medical equipm ent is not indicated for hom e use for thoracic bac k pain co nditions: (1) whirlpools, Jacuzzis, hot tubs, special bath or show er attachm ents; or (2) beds, wate rbeds, mattresses, chairs, recliners, or loungers . Subp. 9. Evaluation of treatment by health care prov ider. The health care provider must evaluate at each visit whether the treatm ent is m edically necessary, and must evaluate whether initial nonsurg ical mana gem ent is effective according to items A to C. No later than the tim e for treatment response established for the specific m oda lity as specified in subparts 3, 4, and 5, the hea lth care provider must evaluate whether the passive, active, injection, or medication treatment

m oda lity is resulting in progressive improvement as s pec ified in item s A to C: A. the employee's subjective complaints of pain or d isability are progressively improving, as evidenced by documentation in the m edical record of decreased distribution, frequency, or intensity of sym ptom s; B. the objective clinical findings are progressively improving, as evidenced by docum entation in the medical record of resoluti on or objectively m easure d improvement in physical signs of injury; and C. the employee's functional statu s, e specially vocational activity, is progressively improving, as evidenced by documentation in the medical record, or succ essive repo rts of w ork a bility, o f les s restrictive limitations o n ac tivity. If there is not progressive improvem ent in at least two items of items A to C, the moda lity must be discontinued or significantly modified or the provider must reconsider the diagnosis. The evaluation of the effectiveness of the treatment m odality can be delegated to an allied hea lth professional working under the direction of the treatin g health care provider bu t re m ain s th e u ltimate respon sibility of the treatin g health care prov ider. Subp. 10. Scheduled and nonscheduled medication. Prescription of controlled substance medications scheduled under Minnesota Statutes, section 152.02, including, without limitation, narcotics, is indicated only for the treatment of severe acute pain. These medications are not indicated in the treatment of pa tients with regional thora cic back pain a fter the first two wee ks . Patients with rad icular pain may require longer periods o f treatm ent. The hea lth care pro vider m ust docu m ent the ration ale for the use of any scheduled medication. Treatment with nonnarcotic medication may be app ropriate during any phase of treatment and inte rm itten tly after a ll other treatment has been discontinued. The prescribing health care provider must determ ine that ongoing m edication is effective treatment for the patient's condition and the m ost c ost-e ffec tive reg imen is u sed . Subp. 11. Spe cific treatm ent p aram eters for regional thoracic back pain. A. Initial nonsurgical treatment m ust be the first phase of treatm ent fo r all patien ts with regional thoracic back pain under subpart 1, item A, su bitem (1). (1) The active, passive, inje ctio n, durable

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Treatment Parameter Rules

medical equipment, and medication treatm ent m odalities and procedures in sub parts 3, 4, 5, 8, and 10, may be used in sequence or simultaneously during the period of initial nonsurgical m ana gem ent, depending on the severity of the con dition. (2) The only therapeutic injections indicated for patients with regional tho racic back pain are trigger point injections, facet joint injections, facet nerve blocks, and epidural blocks, and the ir use must meet the parameters of sub part 5 . (3) After the first week of treatment, initial nonsurgical m anagem ent m ust at a ll tim es contain a c tiv e tre a tmen t m odalities according to the param eters of su bpa rt 4. (4) Initial nonsurgical treatment must be provided in the least intensive setting consistent with quality health care prac tices. (5) Except as provided in subpa rt 3, passive treatment modalities in a clinic setting or requiring atte ndance by a hea lth care provider are not indicated beyond 12 weeks after any passive m oda lity other than bedrest or bracing is first initiated. B. Surgical evaluation or chronic managem ent is indicated if the pa tient co ntinue s 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 d aily life including regular vocational activities. The purpose of surgical evaluation is to determine wheth er surgery is indicate d in the treatmen t of a patien t who has failed to recover with initial non surgical care. If the patient is not a surgical candidate, then chronic m ana gem ent is ind icated . (1) Surgical evaluation may begin as soon as eight week s after, but m ust begin no later than 12 weeks after, beginning initial nonsurgical management. An initial rec om m endation or d ecision against surgical therapy does not prec lude surg ery at a later da te. (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 con dition but the health care provider must follow the param eters of part 5221.6100. Medical im aging stu dies which do not meet these param eters TP-38

are n ot indicated . (3) Surgical evaluation m ay also include diagnostic blocks and injections. These blocks and injec tion s are only indicated if their use is con sistent with the param eters of su bpa rt 1, item H. (4) Surgical evaluation may also include pers ona lity or psychosocial evaluation, consistent with the parameters of sub part 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 f in d i n g s o n m e d i c a l i m a g i n g, dia gn os tic analgesic blocks and injections, if performed, and the patient's ongoing subjective complaints and objective physica l findings . (6) The only surgical procedure indicated for patien ts with reg ional thoracic back pain only is thoracic arthrodesis with or without instrumentation, which must meet the parameters of subpart 6, and part 5 221 .650 0, subpa rt 2, item C. For patien ts w ith failed surgery, dorsal column stimulators or morphine pumps may be indicated consistent with subpart 6, item C. (a) If surgery is indicated, it should be offered to the patient as soon as possible. If the patien t agre es to the proposed surgery it should be performed as expeditiously as possible consistent with sound medical practice, and consistent with any requirem ents of pa rts 5221.6010 to 5221.6500 for prior notification of the insurer or sec ond opinions. (b) If surg ery is no t indicated or if the patient does not wish to proceed with surgery, then the patient is a candidate for c h r o n ic m ana gem ent. C. If the patient continues with symptoms and obje ctive physical findings after surgery has been rendered or the patient refuses surgery or the patient w as n ot a can didate for surgery, and if the patient's condition prev ents the resumption of the regular activities of daily life including regular vocational activities, then the patient may be a candidate for chronic management according to the param eters of part 522 1.66 00. Subp. 12. Spe cific treatm ent p aram eters

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Treatment Parameter Rules

for radicular pain. A. Initia l nonsurgical treatm ent is app ropriate for all patients with radicular pain under subpa rt 1, item A, subitem (2), and must be the first phase of treatment. It must be provided within the param eters of subpart 11, item A, with the following modifications: epidural blocks and nerve root and peripheral nerve block s are the only the rapeutic injections indicated for pa tients with radicular pain on ly. If there is a component of regional thoracic back pain, the rapeutic facet joint injections, facet nerve blocks, and trigger point injections m ay also be ind icated . B. Surgical evaluation or chronic management is indicated if the pa tient co ntinue s 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 vocationa l activities. It shall be provided within the parameters of subpart 11, item B, with the following modifications: the only surgical procedures indicated for pa ti e n ts w i th r a d ic u l a r p a i n a r e decompression or arthrodesis. For patien ts with failed surgery, dorsal column stimulators or morphine pumps m ay be indicated consistent with subpart 6, item C. C. If the patient continues with symptoms and objective physical findings after surgical therapy has been re ndered 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 d aily life including regular vocational activities, then the patient may be a candidate for chronic managem ent. Any course or program of chronic management for patien ts with radicular pain, with or without regional thoracic back pain, m ust m eet all of the para m eters of pa rt 522 1.66 00. Subp. 13. Spe cific treatm ent p aram eters for mye lopathy. A. Patients with myelopathy m ay require emergency surgical evaluation at any tim e during the course of the ir overa ll treatm ent. The dec ision to proceed with surgical evaluation is mad e by the health care provider based on the type of ne urologic changes observe d, th e severity of the changes, the rate of progression of the changes, and the response to any nonsurgical treatm ents. Surgery, if indicated, m ay be performed at any tim e during the course of treatment. Surgical

evaluation and surgery shall be provided with in the parameters of subpart 11, item B, with the following m odifica tions: (1) surgical evaluation and surgical therapy may begin at any time; and (2) the only surgical procedures indicated for patients with myelopathy are decompression and arthrodesis. For patien ts with failed surge ry, dorsal column stimulators or morphine pumps may be indicated consistent with sub part 6 , item C. B. If the health care p rovide r dec ides to proceed with a course of nonsurgical care for a patient with myelopathy, it must follow the param eters of su bpa rt 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 man agement. Any course or program of chronic management for patien ts with myelopathy must meet all of the param eters of pa rt 522 1.66 00. STAT AUTH : MS s 176.103; 176.83 HIST: 19 SR 1412 5221.6300 UPPER EXTREMITY DISORDERS. Subpart 1. Diagnostic procedures for treatment of upper extrem ity disorde rs (UED ). A health care provider shall determine the nature of an upper extremity disorder before initiating treatm ent. A. An appropriate history and physical examination must be performed and documented. Based on the history and physical examination the health care provider m ust at each visit as sign the patient to the appropriate clinical category according to subitems (1) to (6). The diagnosis must be docum ented in the m edical record. Patients m ay have multiple disorders requiring assignment to m ore th an o ne c linical catego ry. This part does not apply to up per e xtrem ity conditions due to a visceral, vascular, infectious, imm unological, metabolic , endocrine, systemic neurologic, or neoplastic disease process, fractures, lacerations, amputations, or sprains or strains with com plete tiss ue d isruption. (1) Epicondylitis. This clinical category

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5221.6210

STATE OF MINNESOTA includes medial epicondylitis and lateral epicondylitis, ICD-9-CM codes 726 .31 and 7 26.3 2. Tendonitis of the forearm, wrist, and h a n d . T h i s c li n ic a l c a te g o r y encompasses any inflamm ation, pain, tenderness, or dysfunction or irritation of a tendon, tendon sheath, tendon insertion, or m usculotendinous junction in the upper extre m ity at or distal to the elbow due to mechanical injury or irritation, including, but not limited to, t h e d i a gn o s e s o f t e n do ni ti s , t e n o s y n o v it is , t e n d o v a g i n i t i s , peritendinitis, extensor tendinitis, de Que rvain's syndrome, intersection syndrome, flexor tendinitis, and trigger digit, including, but not limited to, ICD-9-CM codes 726.4, 726.5, 726.8, 726.9, 726.90, 727, 727.0, 727.00, 727 .03, 727.0 4, 727.05 , and 727 .2. 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, p r o n a to r s yndrome, an ter ior interosseous syndrome, cubital tunnel syndrome, Guyon's canal syndrome, radial tunnel syndrome, posterior i n te r o s s e o u s s y n d ro m e , and W arte nburg 's syndrome, including, but not limited to, ICD-9-CM codes 354, 354.0, 354.1, 354.2, 354.3, 354.8, and 354 .9. Muscle pain syndromes. This clinical category encompasses any painful condition of any of the mu sc les of the upper extrem ity, including the muscles responsible for movement of the shoulder and scapula, characterized by pain and stiffness, including, but not limited to, th e diagnoses of chronic nontraum atic m uscle strain, repetitive strain injury, cervicobrachial syndrome, tension neck syndrome, overuse syndrome, myofascial pain syndrome, myofasciitis, nonspecific m yalg ia, f ib r o s i ti s , f ib r o m y a lg i a , a n d fibromyositis, including, but not limited to, 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 . Shoulder im pingement syndromes, including tendonitis, bursitis, and related conditions. T his clinical category encompasses any TP-40

Treatment Parameter Rules

(2)

(3)

(4)

(5)

inflamm ation, pai n, tendern e s s , dysfunction, or irritation of a tendon, tendon insertion, tendon sheath, musculotendinous junction, or bursa in the shoulder du e to m echanical injury or irritation, including, but not limited to, the diagnoses of impingement syndrome, supraspinatus tendonitis, i nfraspinatus ten do nitis , c a lc ific t e n d o n i ti s , b i c ip ital te nd on it is , subacromial bursitis, subcoracoid bursitis, subdelto id bursitis, and rotator cuff tendinitis, including, but not limited to, 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. (6) Traum atic sprains or strains of the upper extrem ity. This clinical category encompasses an instantaneous or acute injury, as a res ult of a s ingle precipitating event to the ligaments or the muscles of the upper extrem ity including, without limitation, ICD-9-CM codes 840 to 842.19 . Injuries to muscles as a result of repetitive use, or occurring gradually over time without a sin gle precipitating trauma, are considered muscle pain syndromes under sub item (4). Injuries w ith com plete tissue disruption are not sub ject to this pa ram eter. B. Certain laboratory tests may be indicated in the evaluation of a patient with upper extrem ity disorder to rule out infection, m eta bo lic- en do cr ino log ic d i sor der s , tumorous c o n d i ti o n s , s y s t e m i c musculoskeletal dis orders such as rheum ato id arthritis, or sid e effects of medications. Laboratory tests may be ordered at any tim e the hea lth care provider suspects any of these cond itions, but the health care provider must justify the need for the tests ordered with clear docum entatio n of the indica tions. C. Medical imaging evaluation of upper extrem ity disorders m ust be ba sed on the findings of the history and physical examination and cannot be ordered before the health care provider's clinical evaluation of the patien t. Medical imaging may not be performed as a routine procedu re and must comply with the standards in part 5221.6100, subpart 1. The health care provider must document the appropriate indications for any medical imaging studies obtained. D. EMG and nerve c onduc tion studies are

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Treatment Parameter Rules

E.

F.

G.

H.

only appropriate for nerve entrapment disorders and recurrent nerve entrapment after surg ery. The following diagnostic procedures or tests are n ot indicated for diagnosis of upp er ex trem ity disorde rs: (1) surface elec trom yography; (2) therm ography; or (3) som atosensory evok ed poten tials (SSEP) and m oto r evok ed poten tials (MEP). The following diagnostic procedures or tests are considered adjuncts to the physical examination and are not reimbursed separately from the office visit: (1) vibrom etry; (2) neu rom etry; (3) Sem mes- W ein ste in m on of ilamen t testing; or (4) algom etry. Com puterized range of motion or stre ngth measuring tes ts a re not indicated during t h e p e ri o d o f i n it ia l n o ns u r g ic a l m ana gem ent, but may be indicated during the period of chronic management when used in conjunction with a computerized exerc ise p rog ram , w o rk har de nin g prog ram , or wo rk c ond itioning program . During the period of initial nonsurgical m ana gem ent, com pute rized range of motion or strength testing can be performed but m ust be done in conjunction with and are not reim bursed separately from an office visit with a physician, chiropractic evaluation or treatment, or physical or occupational therapy evaluation or trea tm ent. Pe rsonality or psychosocial evaluations may be a useful tool for evaluating patien ts who continue to have problem s de spite app ropriate initial nonsurgical 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. S i n c e m o r e t h a n o n e o f t h e se psychological conditions may be present in a given cas e, the health care provider performing the evaluatio n m ust co nsider all of the following: (1) Is symptom magnification occurring? (2) Does the patient exhibit an emotional reaction to th e injury, such as depression, fear, or anger, which is interfering with recovery? TP-41

(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 patien t have a chronic pain syndrome or psychogenic pain? (7) In cases in which surgery is a poss ible treatm ent, are psychological factors likely to interfere with the potential benefit of the surgery? I. Diagnostic analgesic blocks or injection stud ies. (1) These procedu res are use d to loc alize the source of pain and to diagnose conditions which fail to respo nd to a p p r o p r i a t e i n it ia l n o n s u r g ic a l m ana gem ent. (2) Selection of patients, choice of procedure, and loc alization of the s ite of injection should be determined by documented clinical findings indicating possible patho logic conditions and the sou rce of pa in sym ptom s. (3) These blocks and injections can also be used as therapeutic modalities and as such are subject to the param eters of su bpa rt 5. J. Functional capacity assessment or evaluation is a comprehensive and objective ass ess m ent of a pa tient's ability to perform work task s. The com ponents of a functiona l capa city assess m ent or evaluation include, but are not limited to, neu rom usc uloskeletal screening, tests of manual material handling, assessment of functional m obility, and m easurem ent of postural tolerance. A functional capacity a s s e s s m e n t o r e v a lu a t io n i s a n individualized testing process and the component tests and measurem ents are determined by the patient's condition and the required information. Functional cap acity asses sm ents and eva luations are performed to determ ine an d rep ort a patient's physical capacities in gen eral or to determine work tolerance for a specific job, task , or wo rk activity. (1) Functional capacity assessment or evaluation is not indicated during the first 12 weeks of initial nonsurgical treatm ent. (2) Functional capacity assessment or evaluation is indicated after the first 12 weeks of c are in either of the following circu m stan ces : (a) activity restrictions and capabilities must be identified; or

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Treatment Parameter Rules

(b) there is a question about the patient's ability to return to do a spe cific job . (3) A functional capacity evaluation is not app ropriate to establish baseline performance before treatment, or for subsequent ass ess m ents , to evaluate cha nge during or a fter treatm ent. (4) Only one completed functional capacity evaluation is indica ted per injury. K. Consultations with other health care providers can be initiate d at any tim e by the treating health care pro vider c ons istent w ith acc epte d m edical practice. Subp. 2. General treatment parameters for upp er extrem ity disorders. A. All m edical care for upp er ex trem ity disorders, appropriately assigned to a category of s ubpart 1, item A, is determ ined by the diagnosis and clinical category in sub part 1 , item A, to which the patient has been assigned. General param eters for treatment m odalities are set forth in sub parts 3 to 10 . Specific treatment param ete rs for each clinical category are set fo rth in su bpa rts 11 to 16 as fo llows: (1) sub part 1 1 go vern s ep icondylitis; (2) subpa rt 12 governs tendonitis of the forearm , wrist, an d ha nd; (3) subpa rt 13 governs upp er ex trem ity nerv e en trapm ent syndrom es; (4) subpa rt 14 governs upp er ex trem ity m usc le pain syndrom es; (5) subpa rt 15 g o v e rn s shoulder impingement syndromes; and (6) subpa rt 16 governs traum atic sprains and strains of the upper ex trem ity. The health care pro vider m ust at e ach visit reassess the appropriateness of the clinical category assigned and rea ss ign the patien t if warrante d by new clinical information including symptoms, signs , resu lts of diagnostic testing and opinions, and information obtained from consultations with other health care providers. W hen the clinical categ ory is changed the treatment plan must be appropriately modified to reflect the new clinical category and these changes must be recorded in the medical record. Howev er, a change of clinical category does no t in itself allow the health care provider to continue a therapy or treatment modality past the m axim um duration specified in subparts 3 to 10, or to rep eat a therapy or treatment previously provided for the same injury, unless the treatment or therapy is subsequently delivered to a different part o f the b ody.

W hen treatin g m ore than one clinical category or body part for which the sam e treatment modality is appropriate, then the treatment m od ality s hould be applied sim ulta neously, if possible, to all indicated area s. B. In general, a course of treatmen t must be divided into thre e ph ase s: (1) First, all patients with an upper extre m ity disorder must be given initial nonsurgical m anagement, unless otherwise specified. Initial nonsurgical managem ent may i nclude any combination of the passive, active, injection, dura ble m edical equ ipm ent, and m edication treatm ent m odalities listed in subparts 3, 4, 5, 8, and 10, appropriate to th e clinical cate gory. The period of initial nonsurgical treatment beg ins with the first passive, active, injection, durable medical equipm ent, or m edication m oda lity initiated. Initial nons urgical treatment m u s t r e s u lt in progre ss ive improvement as specified in subpart 9. (2) Second, for patients with persistent s y m p t o m s , i ni t i a l n o n s u r g ic a l managem ent is followed by a period of surgical evaluation. This evaluation should be completed in a tim ely m anner. Surgery, if ind icated , sh ould be performed as expeditiously as possible con sistent with sound medical practice and subparts 6 and 11 to 16, and part 5221.6500. The treating health care provider may do the evaluation, if it is within th e provider's scope of practice, or may refer the em ployee to a cons ultant. (a) Any patient who has had s urgery may require postoperative therapy with active and passive treatment modalities. This therapy can be in addition to any received during the period of initial nonsurgical m ana gem ent. (b) S u r g e r y must f o l lo w t h e param eters in subparts 6 and 11 to 16, and part 5221 .650 0. (c) A decision ag ainst surg ery at this tim e does not preclude a decision for surge ry m ade at a later date . (3) Third, for those patients who are not candidates for surgery or refuse surgery, or who do not have com plete resolution of their sym ptom s with su rg er y, a p e r io d o f c h ro n ic manage ment may be indicated.

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STATE OF MINNESOTA

Treatment Parameter Rules

Chronic m anagem ent m odalities are described in part 5221.6600, and may include durable medical equipm ent is des cribed in su bpart 8. C. A treating health care provider m ay refer the employee for a consultation at any tim e during the course of treatment consistent with ac cep ted m edical 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 H is not indicated beyond 12 calendar weeks after any of the passive m odalities in item C to H are initiated. There are no limitations on the use of passive treatment modalities by the em ployee at hom e. 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 fo llowing app ly: (a) the employee is released to work or is permanently totally disabled a n d the ad ditio na l pa ss ive t r e at m e n t m u s t r e s u l t i n progressive improvement in, or m aintenance of, functional status achieved during the initial 12 wee ks of pa ssive care ; (b) the treatment must not be given on a reg ularly sched uled bas is; (c) the health care provider must docum ent in the medical record a plan to encourage the em ploye e's independence and decreased reliance on health care providers; (d) managem ent of the em ploye e's condition m ust include active treatment m odalities during this period; (e) the additional 12 visits for passive treatment must not delay the required surgical or c hronic pain e v a lu a tion req uir e d by this chapter; and (f) passive care is inappropriate while the em ployee has chronic pain syndrom e. (2) Except as otherwise provided in part 5221.6050, subpart 8, treatment m ay continue beyond the additional 12 visits only after prior approval by the insurer, com m issioner, or compensation judge based on documentation in the medical record of the effectiveness of f u r th e r p a s s i v e t r e a t m e n t i n maintaining em ployab ility; if the employee is per m ane ntly totally TP-43

disabled, or if upon retirement the employee is eligible for ongoing m edical benefits for the work injury, treatment may continue beyond the additional 12 visits only after prior approval by the insurer, com m issioner, or compensation judge based on documentation in the medical record of the effectiveness of further passive treatment in maintaining functional status. C. Adjustmen t or m anipulation of joints includes chiropractic and oste opath ic adju stm ents or m anipulations: (1) tim e for treatment response, three to five trea tm ents ; (2) maxim um treatm ent fre que ncy, up to five times per week the first one to two weeks de cr ea sin g in frequency thereafter; and (3) maxim um treatm ent duration, 12 wee ks. 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 soak s, infrared, whirlpool, and fluidothe rapy. De ep therm al m odalities include diathermy, ultrasound, and m icrow ave. (1) Treatment given in a clinical setting: (a) tim e for treatment response, two to four treatm ents ; (b) maxim um treatment frequency, up to five times per week for the first one to three weeks, decreasing in frequency thereafter; and (c) maxim um treatm ent duration, 12 weeks of treatment in a clinical setting but only if given in con junc tion with other thera pies. (2) H om e use of thermal modalities may be prescribed at any time during the course of treatment. Home use m ay only involve hot packs, hot soaks, hot water bottles, hydrocollators, heating pads, ice pack s, a nd cold soaks which can be applied by the patient without hea lth care provider assistance. Hom e 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 galvanic stim ulation , TEN S, in terferentia l, and m icroc urrent techniques . (1) Treatm ent given in a clinical setting:

5221.6300

STATE OF MINNESOTA

Treatment Parameter Rules

(a) tim e for treatment response, two to four treatm ents ; (b) maxim um treatm ent fre quency, up to five times per week for the first one to three weeks, decreasing in frequency thereafter; and (c) m aximum treatment duration, 12 weeks of treatment in a clinical setting but only if given in con junc tion with other thera pies. (2) H om e use of an electrical stimulation device m ay be presc ribed at any tim e during a cours e of tre atm ent. Initial use of an electrical stimulation device must be in a supervised setting in order to ensure proper electrode placem ent and patient e duc ation: (a) tim e for patient education and training, one to three sessions; and (b) patient m ay use the electrical stim ulation device unsupervised for one m onth , at which tim e effectiveness of the treatment must be reevaluated by the provider before continuing home use of the device. F. A c u p u n c t u r e treatm ents . Endorphin-mediated analgesic therapy i n c lu d e s c l a s s ic a c u p u n c tu re a n d acu pres sure: (1) tim e for treatm ent re spo nse , three to five se ssions; (2) maxim um treatm ent fre que ncy, up to three times pe r week fo r the first one to three weeks, decreasing in frequency thereafter; and (3) maxim um treatment duration, 12 wee ks. G. Ph oresis includes phonopheresis and iontop hore sis: (1) tim e for treatment response, three to five se ssions; (2) maxim um treatm ent fre que ncy, up to three times pe r week fo r the first one to three weeks, decreasing in frequency thereafter; and (3) maxim um treatment duration is nine sessions of either iontophoresis or phonophoresis, or combination, to any one site, with a maximum duration of 12 w eek s for all treatm ent. H. Manual therapy includes soft tissue and joint mobilization and therapeutic massage: (1) tim e for treatm ent re spo nse , three to five trea tm ents ; (2) maxim um treatm ent fre que ncy, up to five times per week for the first one to two weeks decreasing in frequency TP-44

thereafter; and (3) maxim um treatment duration, 12 wee ks. I. S p l i n t s , brac es, and other movem ent-restricting appliances. Bracing required for longer than two weeks must be accompanied by active motion exercises to avoid stiffne ss a nd p rolonged disab ility: (1) tim e for treatment response, ten days; (2) maxim um treatment frequency, limited to intermittent use during times of i n c re a s e d p h y s ic a l s tr e s s o r prophylactic use at work; and (3) maxim um continuous duration, eight weeks. Prophylactic use is allowed indefinitely. J. Rest. Prolonge d res triction of activity and imm obilization are detrim ental to a patient's recovery. Total restriction of use of an affected body part should not be prescribed for more than two weeks, unless rigid imm obilization is required. In cases of rigid imm obilization, active motion exercises at adjacent joints should begin no later than two weeks after application of the imm obilization. Subp. 4. Active treatment m odalities. Active treatment modalities must be used as set forth in items A to D. Use of active treatment modalities may extend past the 12-week limitation on passive treatment modalities so long as the m axim um treatment for the active treatment m oda lity is no t exc eed ed. A. Education must teach the patient about pertinent anato m y and physiology as it relates to upper extremity function for the purpose of injury prevention. Education includes training on posture, biomechanics, and relaxation. The maximum number of treatm ents is three visits, which include an initial education and training session, and two fo llow-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 app ropriate pac ing of activities. Methods include didactic sessions, demonstrations, exercises, and simulated work tasks. The maxim um num ber of treatments is three visits. C. W ork site analysis and modification must examine the patient's work station, tools, and job duties. Recom m endations are made for the alteration of the work station, selection of alternate tools, modification of job duties, and provision of adaptive

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Treatment Parameter Rules

equ ipm ent. The m aximum number of treatm ents is three visits. D. Exercise, which is im porta nt to the success of a nonsurgical treatment program and a return to normal activity, must include active patient participation in activities designed to increase flexibility, strength, endurance, or m usc le relax ation. Exercise m ust, at least in part, be specifically aimed at the m usculatu re of the upper ex trem ity. W hile aerobic exercise may be performed as adjunctive treatm ent this m ust not be the primary focus of the exercise program. Ex ercises m ust be evaluated to dete rm ine if the desired goals are being attained. Strength , flexibility, or endurance must be objectively measured. W hile the provider may objectively measure the treatment response as often as necess ary for optimal care, after the initial evaluation the health care provider may not bill for the testing sooner than two weeks after the initial evalua tion an d m onth ly thereafter. Subitems (1) and (2) govern supervised and uns upervised exercise, except for computerized exercise programs and health clubs, which are governed by part 5221.6600. (1) Supervised exercise. One goal o f an exercise program must be to teach the patient how to maintain and m axim ize any gains experienced from exercise. Self-management of the condition m ust be pro m oted : (a) maxim um treatment frequency, up to three times per week for three weeks. Should decrease with tim e thereafter; and (b) m axim um dura tion, 12 wee ks. (2) Unsupervised exercise must be provided in the least intensive setting and m ay supplem ent or follow the period of s upe rvised ex ercise. Subp. 5. Therapeutic injections. Therapeutic injections include injections of trigger points, sympathetic nerves, peripheral nerves, and soft tissue s. Thera peu tic injections can only be given in conjunction with active treatment m odalities directed to the same anatomical site. Use of injections may extend past the 12-week lim itation on passive modalities, so long as the maxim um treatm ent for injection s in items A to C is not e xce ede d. A. Trigger point injection s: (1) time for treatment response, within 30 m inutes ; (2) maxim um treatment frequency, once per week to any one s ite if a positive response to the first injection at that TP-45

site. If subseq uen t injections at that site dem ons trate diminishing control of symptoms or fail to facilitate objective functional gains, then trigger point injections sho uld be redirected to other areas or discontinued. No m ore than three injections to different sites are reimbursable per patient visit; and (3) maxim um treatment, four injections to any one site over the course of treatm ent. B. Soft tissue injections include injections of a bursa, tendon, te ndon sheath, g anglion, tendon insertion, ligament, or ligament insertion: (1) tim e for treatment response, within one wee k; (2) maxim um treatment frequency, once per month to any one site if a positive response to the first injection. If subsequent injections d em ons trate diminishing control of symptoms or fail to facilitate objective functional gains, then injections should be discontinued. Only three injections to different sites are reim burs able per p atient visit; and (3) maxim um treatm ent, three injections to any one site over the course of treatm ent. C. Injections for median nerve entrapment at the carpa l tunne l: (1) tim e for treatment response, within one wee k; (2) maxim um treatment frequency, can repeat injection in one month if a positive response to the first injection. Only three injections to different sites are reim burs able per p atient visit; and (3) maxim um treatm ent, two inje ctions to any one site over the course of treatm ent. Subp. 6. Surge ry. Surgery m ay only be performed if it meets applicable param ete rs in sub parts 11 to 16 and part 52 21.6 500 . A. In ord er 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 preope rative treatment of the condition. In the postoperative period the maxim um treatm ent duration with passive treatm ent m odalities in a clinical setting from initiation of the first passive m odality used, except bedrest or bracing, is as follows : (1) f o r rotator cuff repa ir, acromioclavicular ligament repair, or any surgery for a clinical cate gory in this part w hi ch requ ire s jo int

5221.6300

STATE OF MINNESOTA

Treatment Parameter Rules

reconstruction, 16 wee ks; or (2) for all other surgery for clinical cate gories in this part, eight we eks. The health care provider must provide the insurer with prio r no tification of nonemergency inpatient surgery according to part 522 1.60 50, subp art 9. B. Repeat surgery must also meet the param eters of subparts 11 to 16 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 requ este d by the insurer. Subp. 7. Chronic ma nage me nt. Ch ronic managem ent of up per e xtrem ity disorders must be provided according to the param eters of part 522 1.66 00. Subp. 8. Durable medical equipm ent. Durable medical equipment is indicate d only in the situations specified in items A to D. The health care pro vider m ust provide the insurer with prior notification as required in items B and C and part 522 1.60 50, subp art 9. A. Splints, brac es, s traps , or su ppo rts may be indicated as specified in subpa rt 3, item I. B. For patien ts using an electrical stimulation device at home, the device and any required supplies are indicated within the parameters of subpart 3, item E. Prior notification of the insurer is required for purchase of the device or for use longer than one month. The insurer may provide the equipment if it is comparable to that pres cribed by the hea lth care pro vider. C. Exercise equipment for home use, inc lud in g b i c yc l e s , tre a d mi l ls, and stairclimbers, are indicated only within the context of a pro gram or p lan of an approved chronic management program. This equipm ent is not indicated during initia l no ns ur gic al c ar e o r du rin g reevaluation and surgical therapy. Prior notification of the insurer is required for the purchase of ho m e ex ercise eq uipm ent. The insurer m ay decide which brand of a prescribed type of equipment is provided to the patien t. If the employer has an app ropriate exe rcise facility on its premises with the prescribed equipment the insurer may mandate use of that facility instead of authorizing purchase of the equipment for hom e us e. (1) I n d ic a tio n s : the p a tient is d e c o n d i ti o n e d and r e q u ir e s r e c o n d i ti o n in g w h i c h c a n b e accomplished only with the use of the prescribed exercise equipment. The health care provider must document

specific rea sons why the exercise equipment is necessary and cannot be replaced with oth er ac tivities. (2) Requirements: the use of the equipment must have specific goals and there must be a specific set of pres cribed ac tivities. D. The follo wing durable m edical equipm ent is not indicated for home use for the upper extre m ity disorders specified in subparts 11 to 16: (1) whirlpools, Jacuzzi, hot tubs, and special bath or shower attachments; or (2) beds, waterbeds, mattresses, chairs, recliners, and lou nge rs. Subp. 9. Evaluation of treatment by health care prov ider. The health care provider must evaluate at each visit wh eth er the treatm ent is m ed ica lly necessar y and w heth er initial nonsurgical treatm ent is e ffec tive according to item s A to C. No later than the tim e for treatment response established for the specific m odality as specified in sub parts 3, 4, and 5, the health care provider must evaluate whether the passive, active, injection, or medication treatm ent m odality is res ulting in progress ive improvem ent as specified in items A to C: A. the employee's subjective complaints of pa in or dis ability are pro gressively improving, as evidenced by documentation in the medical record of decreased distribution, frequency, or intensity of sym ptom s; B. the objective clinical findings are progressively improving as evidenced by documentation in the medical record of resolution or objective ly m easure d improvement in physical signs of inju ry; and C. the employee's functional status, especially vocational activity, is progressively improving, as evidenced by documentation in the medical record, or successive repo rts of w ork a bility, of less restrictive limitations o n ac tivity. If there is not progressive improvem ent in at least two item s in items A to C, the modality must be discontinued or significantly modified or the provider m ust reconsider the diagnosis. The evaluation of the effectiveness of the treatment m oda lity can be delegated to an a llied hea lth professional directly providing the treatment, but rem ain s the ultimate responsibility of the treating hea lth care pro vider. Subp. 10. Scheduled and nonscheduled medication. Prescription of controlled substance medications scheduled under Minnes ota Statutes,

TP-46

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STATE OF MINNESOTA

Treatment Parameter Rules

section 152.02, including, without limitation, narcotics, is indicated only for the treatment of severe acu te pain. Therefore, these medications are not routinely indicated in the treatment of patients with upper extremity disorders. The hea lth care provider must docum ent the rationale for the use of any sched ule d medication. Treatment with nonscheduled medication may be app ropriate during any phase of treatment and inte rm itten tly after all other treatment has been discontinued. Th e presc ribing health care pro vider must determ ine that ongoing m edication is effective treatment for the patient's condition and the m ost c ost-e ffec tive reg imen is u sed . Subp. 11. Spe cific treatm ent p aram eters for epicondylitis. A. Initial nonsurgical m ana gem ent is ap pr op ria te f o r all p atie nts wit h epicondylitis and must be the first phase of treatm ent. (1) The pass ive, ac tive, inje ctio n, durable medical equipment, and medication treatment modalities and procedures specified in subparts 3, 4, 5, 8, and 10, may be used in sequence or sim ulta neously during the period of in i ti a l n o n su r g ic a l m a n a g e m e n t depending on the severity of the condition. After the first week of treatm ent, initial nonsurg ical care must at all tim es include active treatment m oda lities acc ording to subp art 4. (2) Initial nonsurgical management m ust be provided in the least intensive setting con sistent with q uality hea lth care pra ctices. (3) Except as provided in subpart 3, use of passive treatment modalities in a clinic setting or requiring attendance by a hea lth care pro vider for a period in exc ess of 12 wee ks is not ind icated . (4) Use of hom e-based treatment modalities with monitoring by the treating health care provider may continue for up to 12 months. At any tim e during this period the patient may b e a c a n d i d a te f o r c h ro n i c m anagem ent if surgery is ruled out as an a ppro priate treatm ent. B. If the patient continues with symptoms and objective physical findings after initial nonsurgical man agement, and if the patient's condition prevents the resumption of the regular activities of daily life including regular vocational activities, then surgical evaluation or chronic management is indicated. The purpose and goal of surgical evaluatio n is to determine whether

surgery is indicated for the patient who has fa iled to recover with appropriate nonsurgical care or ch ronic m ana gem ent. (1) Surgical evaluation, if indicated, must begin no later than 12 m onths after b e g i n n in g i n i t i a l n o n s u r g i c a l m ana gem ent. (2) Surgical evaluation may include the use of appropriate laboratory and electrodiagnostic testing within the param eters of subpart 1, if not already obtained during the initial evaluation. Repeat testing is not indicated unless there has been an obje ctive change in the patien t's c ondition which in itself would warrant further testing. Failure to improve with therapy does not, by itself, wa rrant furthe r testing . (3) Plain films m ay be approp riate if there is a history of trauma, infection, or inflamm atory disorder and are subject to the general parameters in part 5221.6100, sub part 1 . Other medical imaging studies are n ot indicated . (4) Surgical evaluation may also include pers ona lity or psychological evaluation consistent with the parameters of sub part 1 , item H. (5) Consultation with other health care providers is an important part of surgical evaluatio n of a p atie nt who fails to recover with appropriate initial nonsurgical m anagement. The need for consultation and the choice of consultant will be determined by the diagnostic findings and the patient's condition. Consultation is governed by part 5 221 .605 0, subpa rt 6. (6) If surgery is indicated, it may not be performed until 12 mo nths after initial nonsurgical m anagem ent was begun except in a patient who has had r e s o lu t io n of s ym p t om s w it h app ropriate treatm ent followed by a recurrence with intractable pain. In th is instance, a second surgical opinion must confirm the need for surgery sooner than 12 months after initial nonsurgical man agement was begun. (7) If surg ery is no t indicated, or if the patient does n ot wish to proceed with surgery, then the patient is a candidate for chronic managem ent. An initial recomm endation or decision against surgery does no t preclude surgery at a later da te. C. If the patient continues with symptoms and objective physical findings after surgery or the patient refused surgery or the patient

TP-47

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STATE OF MINNESOTA

Treatment Parameter Rules

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 managem ent according to part 5221.6600. Subp. 12. Spe cific treatm ent p aram eters for tendonitis of forearm, wrist, and hand. A. Except as provided in item B, subitem (3), init ial no ns ur gic al m a n a g e m e nt is app ropriate for all patien ts w ith te ndonitis and must be the first phase of treatm ent. Any course or program of initial nonsurgical managem ent m ust meet all of the para m eters of su bpa rt 11, item A. B. If the patient continues with symptom s and objective physical findings after initial nonsurgical m anagem ent, and if the patient's condition prevents the resumption of the regular activities of daily life including regular vocation al activities , the n surgical evaluation or c hronic m anagem ent is indicated. Surgical evaluation and surgical therapy must meet all of the parameters of subpa rt 11, item B, with the modifications in sub item s (1) to (3). (1) For patie nts with a specific diagnosis of de Q uerv ain's s yndrom e, surgical evaluation and surgical therapy, if indicated, may begin after only two m o n th s o f in i ti a l n o n s u r g ic a l m ana gem ent. (2) For patie nts with a specific diagnosis of trigger finger or trigger thumb, surgical evaluation and potential surgical therapy ma y begin after only one month of initial nonsurgical m ana gem ent. (3) For patients with a locked finger or thumb, surgery m ay be indicated im m ediate ly without any preceding non surgical mana gem ent. C. If the patient continues with symptoms and objective physical findings after surgery, or the patient refused 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 m ana gem ent. Any course or program of chronic m anagem ent for patients with ten donitis m ust m eet all of the param eters of pa rt 522 1.6600. Subp. 13. Spe cific treatm ent p aram eters for nerve entrapment syndromes. A. Initial non sur gica l m ana gem ent is approp riate for all patients with nerve

entrapment syndrome s, ex cep t as specified in subitem (2), and must be the first phase of treatment. Any course or program of initial nonsurgical managem ent must meet all of the param eters of subpa rt 11, item A, with the following modifications: n o n s u rgi cal man ag em en t m ay b e inap prop riate for patients with advanced symptoms and signs of ne rve compression, such as abnormal two-point discrimination, motor weakness, or m uscle atrophy, or for patien ts w ith symptoms of nerve entra pm ent due to acu te trauma. In these cases, imm ediate surgical evaluation m ay be indicated. B. If the patient c ontinu es w ith symptoms and objective physical findings after 12 weeks of initial nonsurgical m anagem ent, an d if the patient's condition prevents the resumption of the regular activities of daily life including regular vocational activities, then surgical evaluation or chronic managem ent is indicated. Surgical evaluation and surgical therapy must meet all of the parameters of subpart 11, item B, with the m odifica tions in sub item s (1) to (3). (1) Surgical evaluation may begin, and surgical therapy m ay be provided, if indicated, after 12 week s of initial nonsurgical m anagem ent, except where im m ediate surgical evaluatio n is indica ted unde r item A. (2) Surgery is indicated if an EMG confirm s the diagnosis, or if there has b e e n t e m p o r a r y r e s o lu t io n o f symptoms lasting at least se ven days with local injection. (3) If there is neither a confirming EMG or app ropriate response to local injection, or if surgery has been previously performed at the sam e site, s urgery is not indicated unless a second opinion con firm s the nee d for surg ery. C. If the patient continues with symptoms and objective physical findings after all surgery, or the patien t refused surgery therapy or the patient was not a candidate for surgery the rapy, and if the patie nt's condition prev ents the resumption of the regular activities of daily life including regular vocational activities, th en the patient may be a candidate fo r chronic m ana gem ent. Any course or p rogram of c hronic managem ent for pa tients w ith nerve entrapment syndrom es m ust m eet all of the param eters of pa rt 522 1.66 00. Subp. 14. Spe cific treatm ent p aram eters

TP-48

5221.6300

STATE OF MINNESOTA

Treatment Parameter Rules

for m uscle p ain syndromes. A. Initial non sur gica l m ana gem ent is app ropriate for all patien ts with m uscle pain syndromes and must be the first phase of treatm ent. Any course or program of initial nonsurgical managem ent must m eet all of the param eters of su bpa rt 11, item A. B. Surgery is not indicated for the treatment of m usc le pain syndrom e. C. If the patient continues with symptoms and obje ctive physical findings after initial nonsurgical managem ent, 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 managem ent. Any course or program of chronic m ana gem ent fo r patien ts with m uscle pain syndrome m ust meet all of the para m eters of pa rt 522 1.66 00. Subp. 15. Spe cific treatm ent p aram eters for shoulder impingement syndromes. A. Initial nonsurgical managem ent is app ropriate for all patients with shoulder impingement syndromes without clinical evidence of rotator cuff tear and must be the first phase of treatm ent. Any course or program of initial nonsurgical managem ent must meet all of the param eters of subpart 11, item A, ex cep t as fo llows: (1) continued nonsurgical management may be inappropriate , and early surgical evaluation may be indicated, for patients with: (a) clinical findings of rotator cuff tear; or (b) acu te rupture of the proximal biceps tendo n; (2) use of ho m e-ba sed treatm ent modalities with monitoring by the hea lth care provider may continue for up to six months. At any time during this period the patient may be a can didate for chronic managem ent if surgery is ruled out as an app ropriate treatm ent. B. If the patient continues with symptoms and objective physical findings after six months of initial nonsurgical m anagem ent, an d if the patient's condition prevents the resumption of the regular activities of d aily life including regular vocational activities, then surgical evaluation or chronic manag em ent is indicated. Surgical evaluation and surgical therapy must m eet all of the parameters of subpart 11, item B, with the m odifica tions in sub item s (1) to (3).

(1) Surgical evaluation must begin no later than six m onths after beginning initial non surgical mana gem ent. (2) Diagnostic injectio n, arthrography, CT-arthrography, or MRI scanning may be indicated as part of the surgical evaluation. (3) The only surgical procedures indicated for patien ts with shoulder impingement syndrome and related conditions are rotator cuff repair, ac rom ioplasty, excision of distal clavicle, excision of bursa, removal of adhesion, or rep air of proximal biceps tendon, all of which must m eet the param eters of part 522 1.65 00, subp art 3. C. If the patient continues with symptoms and objective physical fin dings after surgery, or the patient refuse d su rgery or was no t a cand idate 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 m ana gem ent. Any course or program of chronic managem ent for pa tients w ith shoulder impingement syndrome m ust m eet the pa ram eters of pa rt 522 1.66 00. Subp. 16. Spe cific treatm ent p aram eters for tra um atic sprains and strains of the upper extrem ity. A. Initial nonsurgical management m ust be the first phase of trea tm ent fo r all patien ts with traumatic sprains and strains of the upper extremity without evidence of complete tissue disruption. Any course or program of initial nonsurgical managem ent must m eet all of the param eters of subpart 11. B. Surgery is not indicated for the treatment of traum atic sprains and strains, unless there is clinical evidence of complete tissue disruption. Patients with complete tissue disruption m ay nee d im m ediate surgery. C. If the patient continues with symptoms and objective physical findings after 12 weeks of initial nonsurgical m anagem ent, an d if the patient's condition prevents the resumption of the regular activities of da ily life, including regular vocational activities, then the patient may be a candidate for chronic man agement. Any course or program of chronic management m ust meet all of the param eters of part 522 1.66 00. STAT AUTH : MS s 176.103; 176.83 HIST: 19 SR 1412

TP-49

5221.6300

STATE OF MINNESOTA

Treatment Parameter Rules

5221.6305 REFLEX S Y M P AT H E T IC DYSTROPHY OF THE UPPER AND LOWER EXTR EM ITIE S. Subpa rt 1. Scope. A. This clinical category encompasses any condition of the upp er or lower extre m ity characterized by concurrent presence in the involved extremity of five of the following conditions: edema; local skin color change of red or purple; oste oporosis in underlying bony structures demonstrated by radiograp h; local dyshidrosis; local abn orm ality of skin temperature regulation; reduced passive range of m otion in contiguous joints; local alteration of sk in texture of smooth or shiny; or typical findings of reflex sympathetic dystrophy on bone scan. This clinical category includes, but is not limited to, the diagnoses of reflex sym pathe tic dystrophy, ca usalgia , Sudek's at r op h y , alg on eu ro dys t r o ph y , a n d shoulder-hand syndrome, and including, but not limited to, ICD-9-CM codes 337.9, 354 .4, and 73 3.7. B. Reflex sympathetic dystrophy occurs as a complication of another preceding injury. The treatment parameters of this part refer to the treatment of the body part affected by the reflex sympathetic dystrophy. The treatment for any condition not affected by reflex sym path etic dystroph y continues to be subject to whatever treatmen t parameters otherwise apply. Any treatment under this part for the reflex sym pathe tic dystrophy may be in addition to treatment received for the original con dition. C. Thermography may be used in the diagnosis of reflex sym pathe tic dystrophy, but is consid ered an adjunct to physical examination and is not reimbursed sep arate ly from the office visit. Subp. 2. Initial nonsurgical ma nage me nt. Initial nonsurgical management is appropriate for all patients with reflex sympathetic dystrophy and must be the first phase of treatment. Any course or program of initial nonsurgical m anagem ent is limited to the m odalities specified in items A to D. A. Therapeutic injectio n m odalities. T he only injections allow ed for reflex sym pathe tic d y s tr o p h y a r e s ym p a t h e t ic b l o ck , intravenous infusion of steroids or sym path olytics, or e pidural bloc k. (1) Unless medically contraindicated, sympathetic blocks or the intravenous infusion of steroids or sympatholytics must be used if reflex sym pathe tic

dystrophy has continued for four weeks and the employee remains disabled as a result of the reflex sympathetic dystrophy. (a) T im e for treatment response: within 30 m inutes . (b) M axim um treatm ent fre quency: can repeat an injection at a site if there was a positive res pon se to the first injection. If subsequent injections demonstrate diminishing control of sym ptom s or fail to facilitate objective functional gains, t h e n i n j e c t io n s m u s t b e discontinued. No m ore than three injections to different sites are reim burs able per p atient visit. (c) Maximum treatment duration: m ay be continued as long as injections control sym pto m s and fac ilitate objective fun ctio nal gains, if the p e r i o d o f im p r o v e m e n t is progressively longer with each injection. (2) Epidural block m ay only be performed in patients who had an inco m plete improvement with sympathetic block or intravenous infu sion of steroids or sym path olytics. B. O nly the passive treatment modalities set forth in subitems (1) to (4) are indicated. These passive treatment modalities in a clinical setting or requiring attendance by a hea lth care provider are not indicated beyond 12 weeks from the firs t m oda lity initiated for treatment of the reflex sym path etic dystroph y. (1) Thermal treatm ent includes all superficial and deep heating and cooling modalities. Superficial thermal modalities include hot packs, hot soaks, hot w a te r b o tt le s , hydrocollators, heating pads, ice packs, cold soak s, infrared, w hirlpool, and fluidotherapy. Deep thermal m o d a l i ti e s i n c l u d e d i a t h e r m y , ultrasoun d, and m icrow ave. (a) Treatment given in a clinical setting : i. tim e for treatment response, two to four treatm ents ; ii. m a x i m u m treatmen t frequency, up to five times per week for the first one to three weeks, decreasi n g in frequency thereafter; and iii. m axim um treatment duration, 12 week s of treatment in a clinical setting but only if given

TP-50

5221.6305

STATE OF MINNESOTA

Treatment Parameter Rules

in conjunction with other therapies specified in this sub part. (b) H om e use of therm al modalities m ay be presc ribed at any tim e during the cours e of tre atm ent. H om e 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 pati e n t w i th o u t p r o f e s s io n a l assistance. Hom e use of thermal modalities does not require any special training or m onitoring, other than that usually provided by the health care provider during an office visit. (2) Desensitizing procedures, such as stroking or friction massage, stress loading, an d co ntras t baths: (a) tim e for treatment response, three to five tre atm ents ; (b) maxim um treatmen t frequency in a clinical setting, up to five times per week for the first one to two weeks decreasing in frequency thereafter; and (c) maxim um treatment duration in a clinical setting, 12 weeks. H om e use of desensitizing procedures may be prescribed at any tim e during the cou rse of trea tm ent. (3) Electrical stim ulation includes galvanic stimulation, TEN S, in terferentia l, and m icroc urrent techniques . (a) Treatment given in a clinical setting : i. tim e for treatment response, two to four treatm ents ; ii. m a x i m u m treatmen t frequency, up to five times per week for the first one to three weeks, decreasing in frequency thereafter; and iii. m axim um treatment duration, 12 weeks of treatment in a clinical setting , but only if given in conjunction with other thera pies. (b) H om e use of an electrical stim u l a ti o n de vic e m ay b e prescribed at any time during a course of treatm ent. Initial use of an electrical stimulation device must be in a supervis ed setting in order to ensure proper electrode placem ent and patient education: i. tim e for patient education and TP-51

training, one to three sessions; and ii. patient may use the electrical s timulation device unsupervised for one month, at which time effectiveness of t h e treatmen t m ust b e reevaluated by the provider before continuing home use of the device . (4) A c u p u n c t u r e treatm ents . Endorphin-mediated analgesic therapy includes classic acupuncture and acu pres sure: (a) tim e for treatment response, three to five s ess ions; (b) maxim um treatment frequency, up to three times per week for the first one to three weeks, decreasing in frequency thereafter; and (c) maxim um treatm ent duration, 12 wee ks. C. Active treatment includes supervised and unsupervised exercise. After the first week o f t r e a t m e n t , i n it ia l n o ns u r g ic a l managem ent must include exercise. Exercise is essential for a return to normal activity and m ust include active patient participation in activities designed to increase flex ibility, strength, endurance, or m uscle relaxation. Exercis e must be specif ica lly aim ed at th e in volved musculature. Exercises must be evaluated to determine if the desired goals are being attained. Strength , flexibility, or endurance must be objec tively mea sured. W hile the provider may objectively measure the treatment response as often as necess ary for optimal care, after the initial evaluation the health care pro vider m ay not bill for the tests sooner than two weeks after the initial evaluation, and m onth ly thereafter. (1) Supervised exercise. O ne goal of a supervised exercise program m ust be to teach the patient how to mainta in and m axim ize a ny gains experienced from exercise. Self-managem ent of the cond ition m ust be pro m oted : (a) maxim um treatment frequency, up to five times per week for three weeks. Should decrease in frequency thereafter; and (b) m axim um dura tion, 12 wee ks . (2) Unsupervised exercise must be provided in the least intensive setting and m ay s upplement or follow the period of supervi sed exercise. Ma xim um dura tion is un limited . D. Oral m edicatio ns m ay be indicate d in

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Treatment Parameter Rules

accordance with accepted medical prac tice. Subp. 3. Surge ry. A. Surgical sym pathe cto m y m ay only be performed in patients who had a sustained b u t i n c o m p l e te i m p rove m en t wit h sym path etic blocks by injection. B. Dorsal column stimulator or morphine pum p may be indicated for a patient with neu ropa thic pa in unresp ons ive to all other treatment m odalities w ho is not a can didate for any other therapy and has had a favorable response to a trial screening period. Us e of these devices is indicated only if a second opinion confirm s th at th is treatment is indicated, and a pers ona lity or psychosocial evaluation indicates that the patient is likely to benefit from this treatm ent. Subp. 4. Chronic managemen t. If the patient continues with sym ptom s and ob jective physical findings after surgery, or the patient refuses surgery, or the patient was not a candidate for surg ery, and if the p atient's con dition preve nts the resumption of the regular activities of daily life including regular vocational activities, then the patient m ay be a candidate for chronic managem ent. Any course or p rogram of c hronic managem ent m ust satisfy all of the treatment para m eters of pa rt 522 1.66 00. STAT AUTH : MS s 176.103; 176.83 HIST: 19 SR 1412 5221.6400 INP ATIE NT HO SP ITAL IZAT ION PAR AM ET ER S. Subpa rt 1. General principles. A. The health care provider must provide prior notification of inpatient hospital admission for nonemergency care accord ing to part 522 1.6050, subpart 9. H ospita lizatio n is characterized as inpatient if the patient spe nds at leas t one night in the ho spital. B. Treatment for emergency conditions, including incapacitatin g pain, sh ould not be delayed to provide the insurer with prior notification. Th e adm itting health care provider should notify the insurer within two business days following an emergency admission, or within two business days after the health care provider learns that it is a workers' compensation injury. The medical necessity for the emergency hospitalization is subject to retrospective review, based on the information available a t t h e t i m e o f t h e e m e r g e n cy hos pitalization. C. Unless the patient's condition requires

special care , only ward or sem iprivate accomm odations are indicated. The admitting health care provider must doc um ent the sp ecial care nee ds. D. Adm issions before the day of surgery are indicated only if they are m edically necessary to stabilize the patient before surgery. Adm ission before the day of surgery to perform any or all of a preoperative work-up which could have been completed as an outpatient is not indica ted. E. Inpatient hospitalization solely for physical the rapy, bedrest, or administration of inje cta ble drugs is indicated only if the treatment is othe rwise indicated and the patient's condition makes the patient unable to perform the activities of daily life and participate in the patient's own treatm ent and s elf-ca re. F. Discharge from the hospital must be at the earliest possible date co nsistent with prop er he alth ca re. G. If transfer to a convalescent center or nursing home is indicated, prior notification is required as provided for inpatient hos pitalization. Subp. 2. Specific requirements for hospital admission of patients with low back pain. Hospitalization for low back pain is indicated in the circu m stan ces in item s A to D. A. W h e n the p a t ie n t e x p e ri e n c es incapacitating pain as evidenced by inability to mobilize for activities of da ily living, for exam ple un able to am bulate to the bathroom , and in addition, the intens ity of service during admission meets the criteria in subitems (1) and (2). (1) Physical therapy is necessary at least twice daily for assistance with m obility. He at, cold, ultrasound, and massage therapy alone do not m eet this criterion . (2) M us cle relaxants or nar cotic a n a l g e s ic s are necessary intram uscularly or intravenously for a minimum of three injections in 24 hours. Need for parenteral analgesics is dete rm ined by: (a) an ina bility to take ora l m edications or diet (N.P.O.); or (b) an inab ility to achieve relief with agg ressive o ral analgesics. B. For surgery which is otherwise indicated according to part 5221.65 00 and is appropriately scheduled as an inpatient proc edu re. C. For evaluation and treatment of cauda

TP-52

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STATE OF MINNESOTA

Treatment Parameter Rules

equina syndrome, according to part 522 1.62 00, subp art 13 . D. For evaluation and treatment of foot drop or pro gressive neurologic deficit, according to part 522 1.62 00, subp art 13 . STAT AUTH : MS s 176.103; 176.83 HIST: 19 SR 1412 5221.6500 PARAM ET ER S FO R SUR GIC AL PROCEDU RES. Subpa rt 1. Ge neral. A. The health care provider must provide prior notification according to part 5221.6050, subpa rt 9, before proceeding with any elective inpa tient su rgery. B. Em ergency surgery may proceed without prior notification. The reasonableness and necess ity for the em ergency surgery is subject to retrospective review based on the information available at the time of the em erge ncy surge ry. Subp. 2. Spina l surgery. Initia l nonsurgical, surgical, and chronic managem ent param eters are also included in parts 5 221.6 200, low back pain; 5221.6205, nec k pain; an d 52 21.6 210 , thoracic bac k pain. A. Surgical decompression of a lumba r nerve root or roots includes, but is not limited to, t h e fo l lo w i n g l u m b a r p r o c e du r e s: lam inecto m y, lam inotom y, discecto m y, m i c r o d i s c ec tom y, percutaneous discecto m y, or foram inotomy. W hen p r o v id i n g p r i o r n o t i f i c a t io n f o r decompression of m ultiple nerve roots, the procedu re at each nerve root is subject independently to the requirements of sub item s (1) to (3). (1) Diagnoses: surgical decompression of a lumbar nerve root may be performed for the following diag nos es: (a) intractab le and incapacitating regional low ba ck pain w ith positive nerve root tension signs and an imaging study showing d i s p la c e m e n t of lumbar intervertebral disc which impinges significantly on a nerve root or the thecal s a c, I C D-9-CM code 722 .10; (b) sciatica, ICD-9-CM code 724.3; or (c) lumbosacral radiculopathy or radiculitis, ICD-9-CM code 724.4. (2) Indica tions: both of the following conditions in units (a) and (b) must be satisfied to indicate that the surgery is reas ona bly requ ired. (a) Response to nonsurgical care: the

em ploye e's condition includes one of the following: i. failure to improve with a minimum of eight weeks of initial nonsurgical care; or ii. cauda equina syndrome, ICD-9-CM code 3 44.6 , 344.60, or 344.61; or iii. p r o g r e ssi ve n e u r o lo g i c al deficits. (b) Clinical finding s: the employee exh ibits one of the findings of subunit i in combination with the test results of subunit ii or, in the case of diagnosis in subitem (1), unit (a), a second opinion confirm s that decompression of the lumbar nerve root is th e ap prop riate t r e at m e n t for the patient' s con dition: i. subjective sensory symptoms in a derm ato m al distribution which m ay include radiating pain, burning, numbness, tingling, or paresthesia, or objective clinical findings of nerve root specific motor deficit, including, but not limite d to, foot drop or quadriceps weakness, reflex changes, or positive EMG; and ii. medical imaging test resu lts that correlate with the level of n e r v e r o o t i n v o l v em e n t co ns istent with bo th the subjective an d o bje ctiv e finding s. (3) Repeat surgical decompression of a lumbar nerve root is not indicated at the same nerve root unless a second opinion, if requested by the insurer, con firm s that surg ery is indicated . B. Surgical decom pression of a ce rvical nerve root. Surgical decompression of a cervical nerve root or roots includes, but is not l im i t e d t o , t h e fo l lo w i ng cervical procedures: laminecto m y, lam inotom y, discecto m y, foram inotomy with or without fusion. W hen providing prior notification for decom pression of m ultiple nerve roots, the procedure at each nerve root is subject independently to the requirements of sub item s (1) to (3). (1) Diagnoses: surgical decompression of a cervical nerve root may be performed for the following diagnoses: (a) d i s p la c e m e n t of c e r vi c a l intervertebral disc, ICD-9-CM code

TP-53

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STATE OF MINNESOTA

Treatment Parameter Rules

722.0, excluding fracture; or (b) cervical radiculopathy or radiculitis, ICD-9-CM code 723.4, excluding fracture. (2) Indications: the requirements in units (a) and (b) m ust be sa tisfied to indicate that surge ry is reas ona bly requ ired: (a) response to nonsurgical care, the em ploye e's condition includes one of the following: i. failure to im prove with a minimum of eight weeks of initial nons urgical care; ii. c e r v i c a l co m pr es siv e m yelopathy; or iii. p r o g r e s s i v e n e u r o l o g ic deficits; (b) clinical findings: the employee exhibits one of the findings of subunit i, in combination with the test re sults of su bun it ii: i. subjective sensory symptoms in a derm atom al distribu tion which may include radiating pain, burning, numbness, tingling, or paresthesia, or obje ctive clinical findings of nerve root specific motor deficit, reflex changes, or positive EMG ; and ii. medical imaging test resu lts that correlate with the level of n e r v e r o o t i n v o l v em e n t consistent with both the s ub jective an d o bje ctiv e finding s. (3) S e c o n d op in ions: s u r g ic a l decompression of a cervical nerve root is not indicated for the following conditions, unless a second opinion, if requested by the insurer, confirms that the surge ry is indicated: (a) repeat surgery at sam e level; or (b) request for surgery at the C3-4 level. C. Lumbar arthrodesis with or without instrumentation. (1) Indications: one of the following conditions must be satisfied to indicate that the surgery is reasonably required: (a) unsta ble lumbar vertebral fracture, ICD-9-CM cod es 8 05.4 , 805.5, 806.4, and 806 .5; or (b) for a second or third surgery only, d o c u m e n t e d r e ex t r u s io n o r r e d i s p la c e m e n t o f lu m b a r intervertebral disc, ICD-9-CM code 722.10, after previous successful disc surgery at the same level and TP-54

new lum bar radiculopathy w ith or without incapacitating back pain, I C D -9 -C M cod e 72 4.4. Docum entation under this item must include an MRI or CT scan or a m yelogram; or (c) t r aum atic spinal d e for m ity including a history of compression (wedge) fracture or fractures, I C D-9-CM code 733.1, and demonstrated acquired k yphosis or scoliosis, ICD-9-CM codes 737.1, 737.10, 737.30, 737.41, and 737 .43; or (d) incapacitating low back pain, ICD-9-CM code 724.2, for longer than three months, and one of the following conditions in vo lvin g lumbar seg m ents L-3 and below is pres ent: i. for the first surgery only, degene rative disc disease, ICD-9-CM cod e 72 2.4, 722.5 , 7 2 2 . 6 , o r 7 2 2 .7 , w i t h postoperative documentation of instability created or found at the tim e of surgery, or positive discogram at one or two levels; or ii. pseudoarthrosis, ICD-9-CM cod e 73 3.82 ; iii. for the second or third surgery only, previously operated disc; or iv. spo ndylolisthesis. (2) Contraindications: lum bar arthrodesis is not indicated as the first primary surgical procedu re for a new, a cute lumbosacral disc herniation with unilateral radiating leg pain in a radicular pattern with or without neu rological deficit. (3) Retrospe ctive review: when lumbar arthrodesis is performed to correct i n stability created durin g a decompres sion, lam inec tom y, or dis ce cto m y, a p p r o va l f o r t h e arthrodesis will be based on a retrospective review of the operative repo rt. Subp. 3. Upp er extrem ity surgery. Initial nonsurgical, surgical, and chronic managem ent param eters for upper extrem ity disorders are found in p art 52 21.6 300 , subparts 1 to 16 . A. Ro tator c uff re pair: (1) Diagnoses: rotator cuff surgery may be performed for the following diagnos es: (a) rotator cuff syndrome of the

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STATE OF MINNESOTA

Treatment Parameter Rules

shoulder, ICD-9-CM code 726.1, and allied dis orders: 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 othe r spe cified disorders, ICD-9-CM code 726.19; or (b) tear of rotator cuff, ICD-9-CM code 727 .61. (2) Criteria and indications: in addition to one of the diagnoses in subitem (1), both of the following conditions must be satisfied to indicate th at s urgery is reas ona bly requ ired: (a) response to nonsurgical care : the em ploye e's condition has failed to improve with adequate initial nonsurgical treatment; and (b) clinical findings: the employee exh ibits: i. severe shoulder pain and inab ility to eleva te th e shoulder; or ii. weak or absent abduction and tenderness over rotator cuff, or pain relief obtained with an injection of anesthetic for diagnostic or therapeutic trial; and iii. p o s i t i v e f in d i n g s in arthrogram , MR I, or ultrasound, or positive findings on pre vious arthroscopy, if perform ed. B. Acrom ioplas ty: (1) Diagnosis: acromioplasty may be performed for acromial impingement syndrome, ICD-9-CM codes 726.0 to 726.2. (2) Criteria and indications: in addition to the diagnosis in subitem (1), both of the following conditions mus t be satisfied fo r acrom ioplas ty: (a) response to nonsurgical care : the em ploye e's condition has failed to improve after adequate initial nonsurgical care; and (b) clinical findings: the employee exh ibits pain with active elevation from 90 to 130 degrees and pain a t n i g h t, a n d a p os i t iv e impingem ent test. C. R ep air of a c r o m i o c la v ic u la r or cos toclav icular ligam ents : (1) Diagnosis: surgical repair of acromioclavicular or costoclavicular TP-55

ligam ents m ay be perform ed for a c r o m ioc lav ic u l a r s e p a r a ti o n, ICD -9-C M c ode s 83 1.04 to 831.14 . (2) Criteria and indications: in addition to the diagnosis in subitem (1), the requirements of units (a) and (b) must be satisfied for repair of acromioclavicular or costoclavicular ligam ents : (a) response to nonsurgical care : the em ployee 's condition includes: i. failure to improve after at least a one-week trial period in a suppo rt brace; or ii. separation cannot be reduced and held in a brace; or iii. grade III separation has occurred; and (b) clinical findings: the employee exh ibits localized pain a t the a c r o m i o c la v ic u l a r join t a nd prominent distal clavicle and r a d io g r a p h ic e v id e n c e of separation at the acromioclavicular joint. D. Excision of distal clavicle: (1) Diagnosis: excis ion of the distal clavicle may be performed for the following co nditions: (a) acromi oclavicular separation, I C D -9 -C M codes 831.01 to 831 .14; (b) o s t e o a r t h r o s i s of the acrom ioclavicular jo int, ICD-9-CM codes 715 .11, 715.2 1, and 715.31; or (c) shoulder impingement syndrome. (2) Criteria and indications: in addition to one of the diagnosis in subitem (1), the following conditions must be satisfied for excision of distal clavicle: (a) response to nonsurgical care : the em ploye e's condition fails to improve with adequate initial nonsurgical care; and (b) clinical findings: the employee exh ibits: i. pain at the acromioclavicular joint, with aggravatio n of pa in with motion of shoulder or carrying we ight; ii. confirmation that separation of AC joint is unresolved and prominent distal clavicle, or pain relief obtained with an injection of anesthetic for diagnos tic/the rape utic trial; and iii. s e p a r a t i o n at the

5221.6500

STATE OF MINNESOTA

Treatment Parameter Rules

E.

F.

G.

H.

I.

acromioclavicular joint with w e i g h t- b e a r in g films , o r severe degenerative joint d i s e a s e a t t h e acromioclavicular joint noted on X -rays. Repair of shoulder dislocation or sub luxation (an y procedu re): (1) Diagnosis: surgical repair of a shoulder dislocation may be perform ed for the following diag nos es: (a) recurrent dislocations, ICD-9-CM cod e 71 8.31 ; (b) recurrent subluxations; or (c) persistent instability following traum atic dislocation. (2) Criteria and indications: in add ition to one of the diagnoses in subitem (1), the following clinical findings must exist for repair of a sh oulder dislocation: (a) the employee exhibits a history of m ultip le d i s lo c a t i o n s or subluxations that inhibit activities of daily living; and (b) X-ray findings are consistent with m ultiple d i s lo c a t io n s or sub luxations. Re pair of proxim al biceps tendo n: (1) Diagnosis: surgical repair of a proximal biceps tendon may be performed for proximal rupture of the biceps, ICD-9-CM code 727.62 or 840 .8. (2) Criteria and indications: in a ddition to the diagnosis in subitem (1), both of the following conditions must be satisfied for repair of proximal biceps tend on: (a) the procedure may be done alone or in conjunction with another indicated repair of the rotator cuff; and (b) clinical findings: the employee exh ibits: i. complaint of pain that does not reso lve with a ttem pt to use arm; and ii. palpation of "bulge" in upper asp ect of arm . Epicondylitis. Specific requirements for surgery for epicondylitis are included in part 522 1.63 00, subp art 11 . Tendinitis. Specific requiremen ts for surgery for tendinitis are included in part 522 1.63 00, subp art 12 . Nerve entrapm ent syn drom es. Sp ecific requirem ents for nerve entrapmen t syndromes are included in part 5221.6300, sub part 1 3. TP-56

J. Muscle pain syndromes. Surgery is not indica ted fo r m usc le pain syndrom es. K. Traum atic sprains and strains. Su rgery is not indicated for the treatm ent of traum atic sprains and strains, unless there is clinical evidence of complete tissue disruption. Patients with complete tissue disruption m ay nee d im m ediate surgery. Subp. 4. Low er extrem ity surgery. A. Anterior cruciate li gam e n t ( AC L) recons truction: (1) Diagnoses: surgical repair of the anterior cruciate ligament, including arthroscopic repair, may be performed for the following diag nos es: (a) old disruption of an terior cruciate ligam ent, ICD-9-CM code 717.83; or (b) sprain of cruciate ligament of knee, ICD-9-CM code 844.2. (2) Criteria and indica tions: in a ddition to one of the diagnoses in subitem (1) the conditions in units (a) to (c) must be satisfied for anterior cruciate ligament reconstruction. Pain alone is not an indica tion: (a) the em ployee gives a history of instab ility 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 hyperextens ion oc curred; (b) there are objective clinical findings of positive Lach m an 's sign, positive pivot shift, and/or positive anterior drawer; and (c) there are positive diagnostic findings with arthrogram , MRI, or arthroscopy and there is no evidence of severe com partmental arthritis. B. Pa tella tendon realignm ent or M aquet proc edu re: (1) Diagnosis: patella tendon realignment may be performed for dislocation of patella, open, ICD-9-CM code 836.3, or closed, ICD-9-CM code 836.4, or chronic residuals of dislocation. (2) Criteria and indications : in addition to the diagnosis in subitem (1), all of the following conditions mus t be satisfied for a patella tendon re alignm ent: (a) the em ployee gives a history of rest pain a s we ll as pain with patellofemoral m ovem ent, and recurrent effusion, or recurrent dislocation; and (b) there are objective clinical findings

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STATE OF MINNESOTA

Treatment Parameter Rules

of patellar apprehension, synovitis, lateral track ing, or Q angle greater than 15 degre es. C. Knee joint replacem ent: (1) Diagnoses: knee joint replacement may be performed for degeneration of articular cartilage or meniscus of knee, ICD -9-C M c ode s 71 7.1 to 717 .4. (2) Criteria and indications: in a ddition to the diagnosis in subitem (1), the following conditions must be satisfied for a knee joint replacem ent: (a) clinical findings: the employee exh ibits limited range of motion, night pain in the joint or pa in with weight-bearing, and no significant relief of pain with an adequate course of initial nonsurgical care; and (b) diagnostic find ings: th ere is significant loss or erosion of cartilage to the bone, and positive findings of advanced arthritis and joint destruction with standing films, M RI, or arthro sco py. D. Fusion; ank le, tarsa l, metatarsal: (1) Diagnoses: fus ion may be performed for the following co nditions: (a) malunion or nonunion of fracture of ankle , tarsal, or m eta tarsal, ICD-9-CM code 733.81 or 733.82; or (b) traum atic arthritis (arthropathy), ICD -9-C M c ode 716 .17. (2) Criteria and indications: in a ddition to one of the diagnoses in subitem (1), the following conditions must be satisfied for an ankle, tarsal, or m etatarsal fusion : (a) initial nonsurgical care: the employee m ust have failed to improve with an adequate course of initial nonsurgical care which includ ed: i. imm obilization which may include casting, bracing, shoe m o d i f i c a ti o n , o r o t h e r orthotics; and ii. anti-inflamm atory medications; (b) clinical find ings: i. the employee gives a history of pain which is aggravated by activity and weight-bearing, and relieved by xylocaine injection; and ii. there are objective findings on p h y s ic a l e x a m i n a t io n o f malalignm ent or specific joint l in e tenderness, and TP-57

decreased range of motion; and (c) diagnostic find ings: there are medical im ag ing stu die s con firm ing the pres enc e of: i. loss of articular cartilage and joint sp ace narrowing; ii. b o n e d e f o rm ity wi th hypertro phic spurring and sclerosis; or iii. nonunion or malunion of a fracture. E. Late ral ligam ent ankle recons truction: (1) Diagnoses: ankle reconstruction surgery involving the lateral ligam ents may be performed for the following con ditions: (a) chronic ankle instability, ICD-9-CM code 71 8.87; or (b) grade III sprain, ICD-9-CM codes 845 .0 to 84 5.09 . (2) Criteria and indications: in a ddition to one of the diagnoses in subitem (1), the following conditions must be satisfied for a lateral ligam ent ankle recons truction: (a) initial nonsurgical care: the employee m ust have received an ade qua te c o u r s e o f i nitia l nonsurgical care including, at least: i. im m obilization with su ppo rt, cast, or ankle brace, followed by ii. a p h y s ic a l r e h a b il it a tio n program; and (b) clinical find ings: i. the employee gives a history of ankl e instabilit y and swelling; and ii. there is a positive anterior drawer sign on examination; or iii. there are positive stress X-rays identifying m otio n at ankle or subtalar joint with at least a 15 degree lateral opening at the ankle joint, or dem onstra ble su bta lar m ovem ent, and neg ative to minimal arthritic joint changes on X-ray, or ligamentous injury is shown on M RI scan . (3) Prosthe tic ligam ents: pro sth etic ligam ents are n ot indicated . (4) Implants: req uests for any plastic implant m ust be confirm ed by a sec ond opinion. (5) Calcaneus osteotomy: requests for

5221.6500

STATE OF MINNESOTA calcaneus osteotom ies m ust con firm ed b y a sec ond opinion. be

Treatment Parameter Rules

STAT AUTH : MS s 176.103; 176.83 HIST: 19 SR 1412 5221.6600 CHRONIC MANAGEMENT. Subpart 1. Scope. This part applies to chronic managem ent of all types of physical injuries, even if the injury is n ot s pecifically governed by parts 5221.6200 to 5221.6500. If a patient continues with sym ptoms and physical findings after a ll appro priate initial nonsurgical and surgical treatm ent h as been rendered, and if the patient's condition prevents the resumption of the regular activities of daily life including regular vocational activ ities, then the patient may be a can didate for chron ic m ana gem ent. The purpose of chronic managem ent is twofold: the patient should be made independent of health care providers in the ongoing care of a c hronic condition; and the patient sho uld be return ed to the highest fu nction al statu s rea son ably possible. A. Personality or psychological evaluation may be indicated for patients who are candidates for chronic m ana gem ent. The treating health care provider m ay perform this evaluation or may refer the patient for consultation with an othe r hea lth care provider in order to obtain a psychological evaluation. These evaluations may be used to assess the patient for a number of psychological co nd itions which m ay interfere with recovery from the injury. S i n c e m o r e t h a n o n e o f t h e se psychological conditions may be pre sent in a given case, the health care pro vider performing the evaluatio n m ust co nsider all of the following: (1) Is symptom magnification occurring? (2) Does the patient exhibit an emotional reaction to the injury, such as depression, fea r, or an ger, 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 an y interpersonal co nflicts interfering with recovery? (6) Does the patient have a chronic pain syndrome or psychogenic pain? (7) In cases in which surgery is a possible treatm ent, are psychological factors like ly to interfere with the potential benefit of the surgery? B. Any of the chronic management modalities of sub part 2 m ay be used singly or in

combination as part of a program of chronic m ana gem ent. C. No further passive treatment modalities or the rapeutic injections are indicated, except as o therw ise provide d in pa rts 5221.6200, subpa rt 3, item B; 5221.6205, subpart 3, item B; 5221.6210, subpart 3, item B; and 522 1.63 00, subp art 3, item B. D. No further dia gnostic evaluation is indic ated unless there is the development of symptoms or physical findings which wo uld in themselves wa rrant diagnostic evaluation. E. A program of chronic management m ust include appropriate means by which use of s c h e d u l e d m e d i c a t io n s can be discontinu ed o r severely lim ited. Subp. 2. Chronic managem ent modalities. The health care provider m ust provide prior notification of the chronic managem ent modalities in item s B to F ac cording to part 5 221.6050, subpa rt 9. Prior notification is not required for home-based exercises in item A , unless durable medical equipmen t is prescribed for home use. The insurer may not deny payment for a program of chro nic m ana gem ent that the insurer has previously autho rized fo r an em ployee, eith er in writing or by routine payment for services, without providing the employee and the em ployee 's health care provider with at least 30 days' notice of intent to apply any of the chronic management param eters in part 5221.6600 to future treatm ent. The notice m ust include the spe cific parame ters that will be applied in future determinations of com pen sab ility by the ins urer. A. Hom e-based exercise programs consist of aerobic conditioning, stretching and flexibility exercises, and strengthening exercises done by the patient on a regular basis at home without the need for supervision or attendance by a health care provider. M axim um effectiveness may require the use of certain durable medical equipment that may be prescribed and reimbursed within any applicable treatment parameters in parts 5221.6200 to 522 1.63 05. (1) Indications: exercise is necessary on a long-term basis to m aintain function. (2) Requirements: the patien t sh ould receive specific instruction and training in the exercise program . Repetitions, d u r a ti o n s , a n d f r e q u e n c ie s o f exercises m ust be specified. Any durable medical equipment needed must be prescribed in advance and the insurer must be given prior notification of propo sed purc has e. (3) Treatment period, one to three visits

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Treatment Parameter Rules

for ins truction an d m onitoring. B. He alth clubs: (1) I n d ic a tio n s : the pa tient is d e c o n d i ti o n e d a n d r e q u ir e s a structured environm ent to perform prescribed exe rcise s. The h ealth care provider must docum ent the reasons w h y rec on ditio nin g c a nno t b e accom plished with a home-based prog ram of ex ercise. (2) Requirements: the program m ust have specific prescribed exercises stated in obje ctive term s, for exam ple "30 minutes riding statio nary bic ycle three times per wee k." There must be a specific set of prescribed activities and a specific timetable of progression in those activities, designed so that the goals can be achieved in the prescribed time. There must be a prescribed frequency of attendance and the patient must m aintain ade qua te documentation of attendance. There m ust be a pres cribed du ration of attenda nce . (3) T reatment period, 13 we e k s. Additional periods of treatmen t require additional prior notification of the insurer. Additional periods of treatmen t at a health club are not i n d ic a t e d unless t h e re is documentation of attendance and progression in activities during the preceding period of treatment. If the employer has an app ropriate exercise facility on its premises the insurer may m and ate use of that facility instead of prov iding a hea lth club m em bers hip. C. Com puterized exe rcise prog ram s utilize computer controlled exercise equipment that allows for the isolation of s pecific m uscle groups and the performance of graded exercise designed to increase strength, tone, flexibility, and range of motion. In com bination with computerized range of m otion or strength measuring tests, these programs allow for quantitative m eas urem ent of effo rt and prog ress. (1) Ind ic a tio n s : the pa tient is d e c on dit i o n e d a n d r e q u ir e s a structured environment to accomplish rehabilitation goals. The hea lth care provider m ust document the reasons w h y r e c o n d it io n i n g c a n n ot b e accomplished with a home-based prog ram of ex ercise. (2) Requirements: the program m ust have specific goals sta ted in objective terms, for exam ple "im prov e stre ngth TP-59

of back extensors 50 percent." There must be a spe cific set of prescribed activities and a specific timetable of pro gression in thos e ac tivities, designed so that the goals can be achieved in the prescribed time . There must be a prescribed frequency and dura tion of attendan ce. (3) T reatment peri od, six weeks. Additional periods of treatment require additional prior notification of the insurer. Addition al p eriods of treatment are not indicated unless there is documentation of attendance and progression in activities during the prec eding pe riod of treatm ent. D. W ork conditioning and work hardening programs are intensive, highly structured, job oriented, individualized treatment plans based on an as ses sm ent of the patient's work setting or job demands, and designed to m axim ize the patient's return to work. These programs must include real or si mul ated w o rk ac tiv i ti es. W ork conditioning is designed to restore an individual's neuromusculoskeletal strength, endurance, movem ent, flexibility, and motor control, and cardiopulmonary function. W ork conditioning uses physical conditioning and functional activities related to the individual's work. Services m ay b e provided by one discipline of health care provider. W ork harde ning is des igned to restore an individual's physical, behavioral, and vocation al functions within an interdisciplinary model. W ork hardening addresses the issues of productivity, safety, physical tolerances, and work behaviors. An interdisciplinary team includes profess ionals qua lified to evaluate and treat behavioral, vocatio nal, physical, and func tional need s of th e individual. (1) Indications: the patient is disabled from usual work and requires reconditioning for specific job tasks or activities and the reconditioning cannot be done on the job. T he health care provider must docum ent the reasons why work hardening cannot be accomplished through a structured return to work program. W ork conditioning is indicate d where only physical and functional needs are identified. W ork hardening is indicated where, in addition to physical and functional needs, behavioral and vocational needs are also identified that are n o t o th e rw ise be ing add ressed .

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Treatment Parameter Rules

(2) Requirements: the program m ust have specific goals stated in terms of work activities, fo r exa m ple "ab le to type for 30 minutes." There must be an individualized program of activities and the activities m ust be ch ose n to sim ulate required work activities or to enable the patient to particip ate in simu lated work activities. There must be a specific timetable of progression in those activities, designed so that the goals can be achieved in the prescribed time. The re m ust be a set frequency and hours of attendance and the pro gram m ust m aintain ade qua te d o c u m e n t a t io n of attendance. There must be a set duration of attendance. Activity restrictions must be identified at com pletion of the prog ram . (3) Treatment period, six w eeks. Additional periods of treatment require prior notification of the insurer. Additional periods of treatm ent at a work hardening program o r work conditioning program are not indicated unless there is documentation of atte n d a n c e and progression in activities during the preceding period of treatment or unless there has been a change in the patient's targeted return to work job which necessitates a rede sign of the prog ram . E. Chronic pain manage m ent programs consist of m ultidisciplinary teams who provide coordinated, goal-oriented services to red uce pain disability, improve functional status, promote return to work, and decrease dep end enc e on the health system of persons with chronic pain syndrome. Pain management programs m ust pro vide p hys ica l rehabilitation, education on pain, relaxation training, ps y c h o s o c i a l c o u n s e l in g , m e d i c a l evaluation, and, if indicated , ch em ical dependency evaluation. The program of treatment must be individualized and based on an organized evaluative process for screening and selecting patients. Treatment may be provided in an inpatient setting, outpatient setting, or both as app ropriate. (1) Indications: the patien t is diagnosed as h aving a chronic pain s yndrom e. (2) Requirements: an adm iss ion evaluation m ust be perform ed by a doctor, and a licensed m enta l hea lth professional, each with at least two years experience in evaluation of TP-60

chronic pain patients and chronic pain treatm ent, or one year of formal training in a pain fellowship prog ram . The evaluation must confirm the diagnosis of chronic pain syndrome and a willingness and ability of the patient to benefit from a pain managem ent program. There must be a spe cific se t of pre scribed activities and treatmen ts, and a specific tim eta ble of progression in those activities. There m ust be a set frequency and hours of attendance and the pro gram m ust m aintain ade qua te d o c u m e n t a t io n of attendance. There must be a set dura tion of attendan ce. (3) Treatment period: for initial treatm ent, a maxim um of 20 eight-hour days, though fewer or shorter days can be used, and a maximum duration of four weeks no m atter how many or how long the days prescribed. For aftercare, a m axim um of 12 sessions is allowe d. O nly one com pleted pain mana gement program is indicated for an inju ry. F. Ind ividual or group psychological or psychiatric c oun seling . (1) I n di cati ons: a pe rso nality o r psychosocial evaluation has revealed one or more of the problem s listed in subpa rt 1, item A, wh ich interfere with recovery from the physical injury, but the patient does not need or is not a candidate for a pain management prog ram . (2) Requ iremen ts: there must be a specific set of goals based on the initial pers ona lity or psychosocial evaluation and a timetable for achieving those goals within the prescribed number of treatment or therapy sessions. The re must be a prescribed frequency of attendance and the treating health care provider must m aintain adequ ate docum entation of attendance. T here must be a prescribed duration of treatm ent. (3) Treatm ent period: a maximum of 12 sessions. Only one completed program of individual or group psychological or psychiatric counseling is indica ted fo r an inju ry. STAT AUTH : MS s 176.103; 176.83 HIST: 19 SR 1412

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STATE OF MINNESOTA

Treatment Parameter Rules

5221.8 9 0 0 D I S C IP L IN A R Y AC T IO N ; PENALTIES. Subpa rt 1. Discipline. A hea lth care provider is subject to disciplinary action und er M innesota Statutes, sectio n 176.10 3, for failu re to com ply with the requirem ents in p arts 5 221 .601 0 to 5221.6600 or the violation of any of the provisions of Minnesota Statutes, chapter 176, or other rules or orders issued p ursuan t thereto. Subp. 2. Com plaints. Com plaints about professional behavior or services of hea lth care providers relating to noncompliance with established workers' compensation laws, rules, or orders shall be made in writing to the com m issioner. Th e com m issioner or a designee shall assist a person in filing a com plaint, if necessary. A complaint may be submitted by any person who becomes aware of a violation, including designees of the com m issioner, adm inistrative law jud ges, a nd pre siding officials at judicial proc eed ings. Subp. 3. Review and investigation. The comm issioner sha ll investigate all com plaints to determine whether there has been a violation of established workers' compensation laws, rules, or orders. The comm issioner m ay refe r a m atter to another agency that has jurisdiction over the pro vider's license or c ond uct, or to an agency that has pros ecu ting au thority in the event of suspected theft or fraud or to a peer review organization for an opinion. Absent suspected theft or fraud, providing treatment outside a para m eter s et forth in parts 5221.6020 to 5221.6500 shall not in itself result in a referral to a pro sec uting a utho rity. If an investigation indicates that discipline may be warrante d, th e com m issioner shall determine whether the violation involves inappropriate, unnecess ary, or ex ces sive tre atm ent, or whether the violation involves other statutes or rules. The comm issioner shall take appropriate action acc ording to subp art 6, 7, or 8. Subp. 4. Cooperation with disciplinary proceedings. A health care provider who is the subject of a complaint investigated by the comm issioner under Minnesota Statutes, section 176.103, sh all coopera te fully with th e investigation. Co operatio n in cludes, but is not limited to, responding fully and promptly to any questions raised by the com m issioner relating to the subject of the investigation and providin g copies of records, reports, logs, data, and cost information as re que sted by the c om m ission er to assist in the investigation. The h ealth care provider shall not charge for services but may charge for the cost of copies of medical records, at the rate set in part 5219.03 00, su bpart 2, for this investigation. Coope ration includes a ttending, in person, a meeting scheduled by the comm issioner

for the purpo ses of su bpa rt 5. This sub part does not lim it the health care provider's right to be represe nted by an a ttorne y. Subp. 5. In-person meeting. W hen conferring with the parties to a com plaint is deemed appropriate, the com m issioner shall schedule a meeting for the purpose of clarification of issues, obtaining information, instructing parties to the com plaint, or for the purpose of resolving disciplinary issu es. Subp. 6. Resolution by instruction or written agreem ent. The comm issioner may resolve a com plaint through instruction of a provider, or may enter into stipulated consent agre em ents regarding discipline with a provider in lieu of initiating a contested case or medical services review boa rd proce eding. Subp. 7. Inappropriate, unnecessary, or excessive treatme nt. A. Except as otherwise provided in subparts 3 and 6, if the suspected violation involves a treatment standard set fo rth in pa rts 5221.6020 to 5221.6500 the comm issioner must refer the health care provider to the medical services review board for review under Minnesota S tatutes, se ctio n 176 .103 , subdivision 2, if: (1) the situation requires medical expertise in matters beyond the departm ent's gen eral scop e; (2) wherever pos sible unde r Minnesota Statutes, chapter 176, a final determination has been m ade by a workers' compen sation presidin g official, or provider licensing or registration body that the medical treatment in issue was inappropriate, unnecessary, or excessive; and (3) a pattern of consistently providing i n a p p ro p r ia t e , unn ece ssa ry, or exces sive services exists for three or m ore e m ployee s. B. W here the medical service review board 's report to the comm issioner indicates a violation of trea tm ent standards or other inappropriate, unn ece ssa ry, or exces sive treatment the com m issioner shall order a sanction. Sanctions m ay include, but are not lim ited to, a warning; a fine o f up to $200 per violation; a restriction on p r o v id i n g t re a t m e n t ; requir ing preauthorization by the board, the payor, or the com m ission er for a plan of trea tm ent; a n d s u s p en s i o n f r om rec eiv in g compensation for the provision of treatm ent. C. W ithin 30 days of receipt of the order of sanction, the health care provider may

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STATE OF MINNESOTA

Treatment Parameter Rules

request in writing a review by the c om m i s s io ne r o f th e s a n c ti on in accordance with the procedure set forth in Minnes ota Statutes, section 176.103, subdivision 2a. W ithin 30 days following receipt of the compensation judge's decision review ing the san ction, a provider may petition the workers' compensation court of a ppeals for review according to the procedures in Minnesota Statutes, section 176 .103 , subdivision 2a. Subp. 8. Violations of statutes and rules other than those inv olv ing inappropriate, unnecessa ry, or exces sive treatm ent. If the suspected violation warranting discipline involves a statute or rule other than treatment standards, the comm issioner shall initiate a contested case hearing for disciplinary actio n un der M innesota Statutes, section 176.103, subdivision 3, paragraph (b), and the adm inistrative procedure act in M innesota Statu tes, chap ter 14 . A. Upon petition of the comm issioner and following receipt of the recomm endation of the administrative law judge, the medical services review board m ay issue a fine of up to $200 fo r ea ch violation, or dis qu alify or suspend the health care provider from receiving payment for services, according to Minnesota Statutes, section 176.103, sub division 3, paragraph (b). B. W ithin 30 days after s ervice o f the board 's decision, a provider m ay petition the workers' compensation court of appeals for review according to Minnesota Statutes, sec tion 17 6.421. Subp. 9. Penalties. In addition to disciplinary action under subparts 1 to 8, the comm issioner may asses s a pena lty under part 5220 .2810 if a hea lth care pro vider fails to release existing written medical data according to Minnesota Statutes, section 176.138. A penalty may also be assessed under part 5220.2830 and Minnesota Statutes, section 176 .231 , subdivision 10, if a health care provider fails to provide reports required by part 522 1.04 10. STAT AUTH : MS s 176.103; 176.83 HIST: 19 SR 1412

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