ࡱ> 57234[ Dbjbjmm 4bb:  $$$8\ $R8~""":7777777$8:<*77":H 8*'*'*'":7*'7*'*'V-@-."*"- 7"80R8-T=*'=-.-.=4*'77*'R8= D : State of California Department of Industrial Relations DIVISION OF WORKERS COMPENSATION  [Proposed] Order of the Acting Administrative Director of the Division of Workers Compensation Medical Treatment Utilization Schedule Evidence-Based Updates to the MTUS Effective for Services Rendered on or after [insert effective date] Recently amended Labor Code section 5307.27, subdivision (a), provides that evidence-based updates to the Medical Treatment Utilization Schedule (MTUS) shall be made by issuance of an Administrative Director order exempt from Labor Code sections 5307.3 and 5307.4, and the rulemaking provisions of the Administrative Procedure Act. Pursuant to Labor Code section 5307.27, subdivision (a), the Acting Administrative Director (hereinafter Administrative Director) of the Division of Workers Compensation hereby orders evidence-based updates to the MTUS contained in Title 8, California Code of Regulations, sections 9792.20, 9792.22, 9792.23, et seq. and 9792.24, et seq., as set forth in the Addenda One and Two, which are attached and incorporated by reference into this Order. This order will become effective on the date specified by the Administrative Director, which shall be a date after a 30-day period for public comment and a public hearing. Responses to submitted comments shall be provided prior to the effective date of the updates. This order shall be published on the Department of Industrial Relations, Division of Workers Compensation internet website. IT IS SO ORDERED, Dated: ______________________________ GEORGE P. PARISOTTO Acting Administrative Director of the Division of Workers Compensation ADDENDUM ONE TO ADMINISTRATIVE DIRECTOR ORDER [Effective for services on or after XXXX, 2017] 9792.20. Medical Treatment Utilization Schedule - Definitions. As used in this Article: (a) ACOEM means the American College of Occupational and Environmental Medicine's Occupational Medicine Practice Guidelines published by the Reed Group containing evidenced-based medical treatment guidelines for conditions commonly associated with the workplace. ACOEM guidelines may be obtained from the Reed Group (http://go.reedgroup.com/mtus). ACOEM guidelines may be obtained from the American College of Occupational and Environmental Medicine, 25 Northwest Point Blvd., Suite 700, Elk Grove Village, Illinois, 60007-1030 ( HYPERLINK "http://www.acoem.org" www.acoem.org). (b) - (l) [No change] Note: Authority cited: Sections 133, 4603.5, 5307.3 and 5307.27, Labor Code. Reference: Sections 77.5, 4600, 4604.5 and 5307.27, Labor Code. 9792.22. General Approaches. (a) The Administrative Director adopts and incorporates by reference into the MTUS specific guidelines set forth below from the American College of Occupational and Environmental Medicine's Occupational Medicine Practice Guidelines (ACOEM Practice Guidelines) for the following chapters. A copy may be obtained from the American College of Occupational and Environmental Medicine, 25 Northwest Point Blvd., Suite 700, Elk Grove Village, Illinois, 60007-1030 ( HYPERLINK "http://www.acoem.org" www.acoem.org). (1) Prevention (ACOEM Practice Guidelines, 2nd Edition (2004), Chapter 1). (2) General Approach to Initial Assessment and Documentation (ACOEM Practice Guidelines, 2nd Edition (2004), Chapter 2). (3) Initial Approaches to Treatment (ACOEM Practice Guidelines, 2nd Edition (2004), Chapter 3). Initial Approaches to Treatment (ACOEM June 30, 2017). (4) Cornerstones of Disability Prevention and Management (ACOEM Practice Guidelines, 2nd Edition (2004), Chapter 5). Note: Authority cited: Sections 133, 4603.5, 5307.3 and 5307.27, Labor Code. Reference: Sections 77.5, 4600, 4604.5 and 5307.27, Labor Code. 9792.23. Clinical Topics. (a) The Administrative Director adopts and incorporates by reference a series of medical treatment guidelines into the MTUS specific clinical topic medical treatment guidelines in the series of sections commencing with 9792.23.1. Clinical topics apply to the initial management and subsequent treatment of presenting complaints specific to the body part. The Administrative Director adopts and incorporates by reference a series of medical treatment guidelines into the MTUS commencing with section 9792.23.1. (b) For all conditions or injuries not addressed in the MTUS treatment guidelines, the authorized treatment and diagnostic services in the initial management and subsequent treatment for presenting complaints shall be in accordance with other scientifically and evidence-based medical treatment guidelines that are nationally recognized by the medical community pursuant to section 9792.21(d)(1). (1) In providing treatment using other guidelines pursuant to subdivision (b) above and in the absence of any cure for the patient who continues to have pain lasting three or more months from the initial onset of pain, the chronic pain medical treatment guidelines in section 9792.24.2 shall apply and supersede any applicable chronic pain guideline in accordance with section 9792.23(b). (2) In providing treatment using other guidelines pursuant to subdivision (b) above and if surgery is performed, the postsurgical treatment guidelines in section 9792.24.3 for postsurgical physical medicine shall apply together with any other applicable treatment guidelines found in the MTUS or in accordance with section 9792.23(b). The postsurgical treatment guidelines supersede any applicable postsurgical treatment guideline in accordance with section 9792.23(b). Note: Authority cited: Sections 133, 4603.5, 5307.3 and 5307.27, Labor Code. Reference: Sections 77.5, 4600, 4604.5 and 5307.27, Labor Code. 9792.23.1. Neck and Upper Back Complaints. Cervical and Thoracic Spine Disorders Guideline. (a) The Administrative Director adopts and incorporates by reference the Neck and Upper Back Complaints Chapter (ACOEM Practice Guidelines, 2nd Edition (2004), Chapter 8) into the MTUS from the ACOEM Practice Guidelines. The Administrative Director adopts and incorporates by reference the Cervical and Thoracic Spine Disorders Guideline (ACOEM May 27, 2016) into the MTUS from the ACOEM Practice Guidelines. (b) In the course of treatment for neck and upper back complaints where acupuncture or acupuncture with electrical stimulation is being considered, the acupuncture medical treatment guidelines in section 9792.24.1 shall apply and supersede the text in the ACOEM chapter referenced in subdivision (a) above relating to acupuncture. (c) If recovery has not taken place with respect to pain by the end of algorithm 8-5, the chronic pain medical treatment guidelines in section 9792.24.2 shall apply. (d) If surgery is performed in the course of treatment for neck and upper back complaints, the postsurgical treatment guidelines in section 9792.24.3 for postsurgical physical medicine shall apply together with any other applicable treatment guidelines found in the MTUS. In the absence of any cure for the patient who continues to have pain that persists beyond the anticipated time of healing, the chronic pain medical treatment guidelines in section 9792.24.2 shall apply. Note: Authority cited: Sections 133, 4603.5 and 5307.27, Labor Code. Reference: Sections 77.5, 4600, 4604.5 and 5307.27, Labor Code. 9792.23.2. Shoulder Complaints. Shoulder Disorders Guideline. (a) The Administrative Director adopts and incorporates by reference the Shoulder Complaints Chapter (ACOEM Practice Guidelines, 2nd Edition (2004), Chapter 9) into the MTUS from the ACOEM Practice Guidelines. The Administrative Director adopts and incorporates by reference the Shoulder Disorders Guideline (ACOEM August 1, 2016) into the MTUS from the ACOEM Practice Guidelines. (b) If recovery has not taken place with respect to pain by the end of algorithm 9-5, the chronic pain medical treatment guidelines in section 9792.24.2 shall apply. (c) If surgery is performed in the course of treatment for shoulder complaints, the postsurgical treatment guidelines in section 9792.24.3 for postsurgical physical medicine shall apply together with any other applicable treatment guidelines found in the MTUS. In the absence of any cure for the patient who continues to have pain that persists beyond the anticipated time of healing, the chronic pain medical treatment guidelines in section 9792.24.2 shall apply. Note: Authority cited: Sections 133, 4603.5 and 5307.27, Labor Code. Reference: Sections 77.5, 4600, 4604.5 and 5307.27, Labor Code. 9792.23.3. Elbow Disorders. Elbow Disorders Guideline. (a) The Administrative Director adopts and incorporates by reference the Elbow Disorders Chapter (ACOEM Practice Guidelines, 2nd Edition (Revised 2007), Chapter 10) into the MTUS from the ACOEM Practice Guidelines. The Administrative Director adopts and incorporates by reference the Elbow Disorders Guideline (ACOEM 2013) into the MTUS from the ACOEM Practice Guidelines. (b) In the course of treatment for elbow complaints where acupuncture or acupuncture with electrical stimulation is being considered, the acupuncture medical treatment guidelines in section 9792.24.1 shall apply and supersede the text in the ACOEM chapter referenced in subdivision (a) above relating to acupuncture. (c) If recovery has not taken place with respect to pain by the end of the Elbow Algorithm 10-5, the chronic pain medical treatment guidelines in section 9792.24.2 shall apply and supersede the text in the ACOEM chapter referenced in subdivision (a) above relating to chronic pain. (d) If surgery is performed in the course of treatment for elbow complaints, the postsurgical treatment guidelines in section 9792.24.3 for postsurgical physical medicine shall apply together with any other applicable treatment guidelines found in the MTUS. In the absence of any cure for the patient who continues to have pain that persists beyond the anticipated time of healing, the chronic pain medical treatment guidelines in section 9792.24.2 shall apply. Note: Authority cited: Sections 133, 4603.5, 5307.3 and 5307.27, Labor Code. Reference: Sections 77.5, 4600, 4604.5 and 5307.27, Labor Code. 9792.23.4. Forearm, Wrist, and Hand Complaints. Hand, Wrist, and Forearm Disorders Guideline. (a) The Administrative Director adopts and incorporates by reference the Forearm, Wrist, and Hand Complaints Chapter (ACOEM Practice Guidelines, 2nd Edition (2004), Chapter 11) into the MTUS from the ACOEM Practice Guidelines. The Administrative Director adopts and incorporates by reference the Hand, Wrist, and Forearm Disorders Guideline (ACOEM June 30, 2016) into the MTUS from the ACOEM Practice Guidelines. (b) In the course of treatment for forearm, wrist, and hand complaints where acupuncture or acupuncture with electrical stimulation is being considered, the acupuncture medical treatment guidelines in section 9792.24.1 shall apply and supersede the text in the ACOEM chapter referenced in subdivision (a) above relating to acupuncture. (c) If recovery has not taken place with respect to pain by the end of algorithm 11-5, the chronic pain medical treatment guidelines in section 9792.24.2 shall apply. (d) If surgery is performed in the course of treatment for forearm, wrist, and hand complaints, the postsurgical treatment guidelines in section 9792.24.3 for postsurgical physical medicine shall apply together with any other applicable treatment guidelines found in the MTUS. In the absence of any cure for the patient who continues to have pain that persists beyond the anticipated time of healing Note: Authority cited: Sections 133, 4603.5, 5307.3 and 5307.27, Labor Code. Reference: Sections 77.5, 4600, 4604.5 and 5307.27, Labor Code. 9792.23.5. Low Back Complaints. Low Back Disorders Guideline. (a) The Administrative Director adopts and incorporates by reference the Low Back Complaints (ACOEM Practice Guidelines, 2nd Edition (2004), Chapter 12) into the MTUS from the ACOEM Practice Guidelines. The Administrative Director adopts and incorporates by reference the Low Back Disorders Guideline (ACOEM February 24, 2016) into the MTUS from the ACOEM Practice Guidelines. (b) In the course of treatment for low back complaints where acupuncture or acupuncture with electrical stimulation is being considered, the acupuncture medical treatment guidelines in section 9792.24.1 shall apply and supersede the text in the ACOEM chapter referenced in subdivision (a) above relating to acupuncture. (c) If recovery has not taken place with respect to pain by the end of algorithm 12-5, the chronic pain medical treatment guidelines in section 9792.24.2 shall apply. (d) If surgery is performed in the course of treatment for low back complaints, the postsurgical treatment guidelines in section 9792.24.3 for postsurgical physical medicine shall apply together with any other applicable treatment guidelines found in the MTUS. In the absence of any cure for the patient who continues to have pain that persists beyond the anticipated time of healing, the chronic pain medical treatment guidelines in section 9792.24.2 shall apply. Note: Authority cited: Sections 133, 4603.5, 5307.3 and 5307.27, Labor Code. Reference: Sections 77.5, 4600, 4604.5 and 5307.27, Labor Code. 9792.23.6. Knee Complaints. Knee Disorders Guideline. (a) The Administrative Director adopts and incorporates by reference the Knee Complaints Chapter (ACOEM Practice Guidelines, 2nd Edition (2004), Chapter 13) into the MTUS from the ACOEM Practice Guidelines. The Administrative Director adopts and incorporates by reference the Knee Disorders Guideline (ACOEM October 28, 2015) into the MTUS from the ACOEM Practice Guidelines. (b) In the course of treatment for knee complaints where acupuncture or acupuncture with electrical stimulation is being considered, the acupuncture medical treatment guidelines in section 9792.24.1 shall apply and supersede the text in the ACOEM chapter referenced in subdivision (a) above relating to acupuncture. (c) If recovery has not taken place with respect to pain by the end of algorithm 13-5, the chronic pain medical treatment guidelines in section 9792.24.2 shall apply. (d) If surgery is performed in the course of treatment for knee complaints, the postsurgical treatment guidelines in section 9792.24.3 for postsurgical physical medicine shall apply together with any other applicable treatment guidelines found in the MTUS. In the absence of any cure for the patient who continues to have pain that persists beyond the anticipated time of healing, the chronic pain medical treatment guidelines in section 9792.24.2 shall apply. Note: Authority cited: Sections 133, 4603.5 and 5307.27(a), Labor Code. Reference: Sections 77.5, 4600, 4604.5 and 5307.27(a), Labor Code. 9792.23.7. Ankle and Foot Complaints. Ankle and Foot Disorders Guideline. (a) The Administrative Director adopts and incorporates by reference the Ankle and Foot Complaints Chapter (ACOEM Practice Guidelines, 2nd Edition (2004), Chapter 14) into the MTUS from the ACOEM Practice Guidelines. The Administrative Director adopts and incorporates by reference the Ankle and Foot Disorders Guideline (ACOEM September 2015) into the MTUS from the ACOEM Practice Guidelines. (b) In the course of treatment for ankle and foot complaints where acupuncture or acupuncture with electrical stimulation is being considered, the acupuncture medical treatment guidelines in section 9792.24.1 shall apply and supersede the text in the ACOEM chapter referenced in subdivision (a) above relating to acupuncture. (c) If recovery has not taken place with respect to pain by the end of algorithm 14-5, the chronic pain medical treatment guidelines in section 9792.24.2 shall apply. (d) If surgery is performed in the course of treatment for ankle and foot complaints, the postsurgical treatment guidelines in section 9792.24.3 for postsurgical physical medicine shall apply together with any other applicable treatment guidelines found in the MTUS. In the absence of any cure for the patient who continues to have pain that persists beyond the anticipated time of healing, the chronic pain medical treatment guidelines in section 9792.24.2 shall apply. Note: Authority cited: Sections 133, 4603.5 and 5307.27, Labor Code. Reference: Sections 77.5, 4600, 4604.5 and 5307.27, Labor Code. 9792.23.8. Stress Related Conditions. (a) The Administrative Director adopts and incorporates by reference the Stress Related Conditions Chapter (ACOEM Practice Guidelines, 2nd Edition (2004), Chapter 15) into the MTUS from the ACOEM Practice Guidelines. The Administrative Director adopts and incorporates by reference the Chronic Pain Guideline (ACOEM May 2017) into the MTUS from the ACOEM Practice Guidelines for psychological treatment and evaluation related to chronic pain. If the injured workers psychological condition, treatment, or evaluation is unrelated to chronic pain, then medical care and evaluation shall be in accordance with other medical treatment guidelines or peer-reviewed studies found by applying the Medical Evidence Search Sequence set forth in section 9792.21.1. Note: Authority cited: Sections 133, 4603.5 and 5307.27, Labor Code. Reference: Sections 77.5, 4600, 4604.5 and 5307.27, Labor Code. 9792.23.9. Eye. Eye Disorders Guideline. (a) The Administrative Director adopts and incorporates by reference the Eye Disorders Chapter (ACOEM Practice Guidelines, 2nd Edition (2004), Chapter 16) into the MTUS from the ACOEM Practice Guidelines. The Administrative Director adopts and incorporates by reference the Eye Disorders Guideline (ACOEM April 1, 2017) into the MTUS from the ACOEM Practice Guidelines. (b) If recovery has not taken place with respect to pain by the end of algorithm 16-6, the chronic pain medical treatment guidelines in section 9792.24.2 shall apply. Note: Authority cited: Sections 133, 4603.5 and 5307.27, Labor Code. Reference: Sections 77.5, 4600, 4604.5 and 5307.27, Labor Code. 9792.23.10. Hip and Groin Guideline. The Administrative Director adopts and incorporates by reference the Hip and Groin Guideline (ACOEM May 1, 2011) into the MTUS from the ACOEM Practice Guidelines. Note: Authority cited: Sections 133, 4603.5 and 5307.27, Labor Code. Reference: Sections 77.5, 4600, 4604.5 and 5307.27, Labor Code. 9792.23.11. Occupational/Work-Related Asthma Medical Treatment Guideline. The Administrative Director adopts and incorporates by reference the Occupational/Work-Related Asthma Medical Treatment Guideline (ACOEM January 4, 2016) into the MTUS from the ACOEM Practice Guidelines. Note: Authority cited: Sections 133, 4603.5 and 5307.27, Labor Code. Reference: Sections 77.5, 4600, 4604.5 and 5307.27, Labor Code. 9792.23.12. Occupational Interstitial Lung Disease Guideline. The Administrative Director adopts and incorporates by reference the Occupational Interstitial Lung Disease Guideline (ACOEM January 4, 2016) into the MTUS from the ACOEM Practice Guidelines. Note: Authority cited: Sections 133, 4603.5 and 5307.27, Labor Code. Reference: Sections 77.5, 4600, 4604.5 and 5307.27, Labor Code. 9792.24.1. Acupuncture Medical Treatment Guidelines. (a) As used in this section, the following definitions apply: Guidance for acupuncture treatment and evaluation are contained in the applicable Clinical Topics guidelines, and/or Chronic Pain Guideline, and/or Opioid Guideline. (1) Acupuncture is used as an option when pain medication is reduced or not tolerated, it may be used as an adjunct to physical rehabilitation and/or surgical intervention to hasten functional recovery. It is the insertion and removal of filiform needles to stimulate acupoints (acupuncture points). Needles may be inserted, manipulated, and retained for a period of time. Acupuncture can be used to reduce pain, reduce inflammation, increase blood flow, increase range of motion, decrease the side effect of medication-induced nausea, promote relaxation in an anxious patient, and reduce muscle spasm. (2) Acupuncture with electrical stimulation is the use of electrical current (micro-amperage or milli-amperage) on the needles at the acupuncture site. It is used to increase effectiveness of the needles by continuous stimulation of the acupoint. Physiological effects (depending on location and settings) can include endorphin release for pain relief, reduction of inflammation, increased blood circulation, analgesia through interruption of pain stimulus, and muscle relaxation. It is indicated to treat chronic pain conditions, radiating pain along a nerve pathway, muscle spasm, inflammation, scar tissue pain, and pain located in multiple sites. (3) Chronic pain for purposes of acupuncture means chronic pain as defined in section 9792.20(c). (b) Application (1) These guidelines apply to acupuncture or acupuncture with electrical stimulation when referenced in the clinical topic medical treatment guidelines in the series of sections commencing with 9792.23.1 et seq., or in the chronic pain medical treatment guidelines contained in section 9792.24.2. (c) Frequency and duration of acupuncture or acupuncture with electrical stimulation may be performed as follows: (1) Time to produce functional improvement: 3 to 6 treatments. (2) Frequency: 1 to 3 times per week (3) Optimum duration: 1 to 2 months (d) Acupuncture treatments may be extended if functional improvement is documented as defined in Section 9792.20(e). (e) It is beyond the scope of the Acupuncture Medical Treatment Guidelines to state the precautions, limitations, contraindications or adverse events resulting from acupuncture or acupuncture with electrical stimulations. These decisions are left up to the acupuncturist. Note: Authority cited: Sections 133, 4603.5, 5307.3 and 5307.27, Labor Code. Reference: Sections 77.5, 4600, 4604.5 and 5307.27, Labor Code. 9792.24.2. Chronic Pain Medical Treatment Guidelines. (a) The Chronic Pain Medical Treatment Guidelines (July 2016), consisting of two parts, are adopted and incorporated by reference into the MTUS. Part 1 is entitled Introduction. Part 2 is entitled the Official Disability Guidelines (ODG) Treatment in Workers' Compensation - Pain (Chronic) consisting of an edited version from the Official Disability Guidelines published on April 6, 2015, which the Division of Workers' Compensation has adapted with permission from the publisher. A copy of the Chronic Pain Medical Treatment Guidelines may be obtained from the Medical Unit, Division of Workers' Compensation, P.O. Box 71010, Oakland, CA 94612-1486, or from the DWC web site at  HYPERLINK "http://www.dwc.ca.gov" http://www.dwc.ca.gov. The Administrative Director adopts and incorporates by reference the Chronic Pain Guideline (ACOEM May 15, 2017) into the MTUS from the ACOEM Practice Guidelines for the treatment and evaluation of patients who have chronic pain as defined in section 9792.20. This guideline addresses a general approach to patients with chronic pain and the psychological and behavioral aspects of chronic pain. This guideline also addresses a few specific chronic pain disorders (i.e., complex regional pain syndrome, fibromyalgia, neuropathic pain). Guidance for treatment and evaluation of chronic pain disorders not specifically addressed in this guideline are contained in the Clinical Topics guidelines and/or Opioid Guideline. (b) The Chronic Pain Medical Treatment Guidelines apply when the patient has chronic pain as defined in section 9792.20. (c) When a patient has chronic pain and the treatment for the condition is covered in the Clinical Topics section of the MTUS but is not addressed in the Chronic Pain Medical Treatment Guidelines, the Clinical Topics section applies to that treatment. (d) When a patient has chronic pain and the treatment is addressed in both the Chronic Pain Medical Treatment Guidelines and the specific guideline found in the Clinical Topics section of the MTUS or if the treatment is only addressed in the Chronic Pain Medical Treatment Guidelines, then the Chronic Pain Medical Treatment Guidelines shall apply. Note: Authority cited: Sections 133, 4603.5, 5307.3 and 5307.27, Labor Code. Reference: Sections 77.5, 4600, 4604.5 and 5307.27, Labor Code. 9792.24.3. Postsurgical Treatment Guidelines. (a) As used in this section, the following definitions applyGuidance for postsurgical treatment and evaluation are contained in the Clinical Topics guidelines, and/or Chronic Pain Guideline and/or Opioid Guideline. (1) General course of therapy means the number of visits and/or time interval which shall be indicated for postsurgical treatment for the specific surgery in the postsurgical physical medicine treatment recommendations set forth in subdivision (d)(1) of this section. (2) Initial course of therapy means one half of the number of visits specified in the general course of therapy for the specific surgery in the postsurgical physical medicine treatment recommendations set forth in subdivision (d)(1) of this section. (3) Postsurgical physical medicine period means the time frame that is needed for postsurgical treatment and rehabilitation services beginning with the date of the procedure and ending at the time specified for the specific surgery in the postsurgical physical medicine treatment recommendations set forth in subdivision (d)(1) of this section. For all surgeries not covered by these guidelines the postsurgical physical medicine period is six (6) months. (4) Surgery means a procedure listed in the surgery chapter of the Official Medical Fee Schedule with follow-up days of 90 days. (5) Visit means a date of service to provide postsurgical treatment billed using the physical medicine section of the Official Medical Fee Schedule. (b) Application (1) The postsurgical treatment guidelines apply to visits during the postsurgical physical medicine period only and to surgeries as defined in these guidelines. At the conclusion of the postsurgical physical medicine period, treatment reverts back to the applicable 24-visit limitation for chiropractic, occupational and physical therapy pursuant to Labor Code section 4604.5(d)(1). (c) Postsurgical Patient Management (1) Only the surgeon who performed the operation, a nurse practitioner or physician assistant working with the surgeon, or a physician designated by that surgeon can make a determination of medical necessity and prescribe postsurgical treatment under this guideline. (2) The medical necessity for postsurgical physical medicine treatment for any given patient is dependent on, but not limited to, such factors as the comorbid medical conditions; prior pathology and/or surgery involving same body part; nature, number and complexities of surgical procedure(s) undertaken; presence of surgical complications; and the patient's essential work functions. (3) If postsurgical physical medicine is medically necessary, an initial course of therapy may be prescribed. With documentation of functional improvement, a subsequent course of therapy shall be prescribed within the parameters of the general course of therapy applicable to the specific surgery. If it is determined that additional functional improvement can be accomplished after completion of the general course of therapy, physical medicine treatment may be continued up to the end of the postsurgical physical medicine period. (4) Patients shall be reevaluated following continuation of therapy when necessary or no later than every forty-five days from the last evaluation to document functional improvement to continue physical medicine treatment. Frequency of visits shall be gradually reduced or discontinued as the patient gains independence in management of symptoms and with achievement of functional goals. (A) In the event the patient sustains an exacerbation related to the procedure performed after treatment has been discontinued and it is determined that more visits are medically necessary, physical medicine treatment shall be provided within the postsurgical physical medicine period. (B) In cases where no functional improvement is demonstrated, postsurgical treatment shall be discontinued at any time during the postsurgical physical medicine period. (5) Treatment is provided to patients to facilitate postsurgical functional improvement. (A) The surgeon who performed the operation, a nurse practitioner or physician assistant working with the surgeon, or physician designated by that surgeon, the therapist, and the patient should establish functional goals achievable within a specified timeframe. (B) Patient education regarding postsurgical precautions, home exercises, and self-management of symptoms should be ongoing components of treatment starting with the first visit. Intervention should include a home exercise program to supplement therapy visits. (C) Modalities (CPT [as defined in section 9789.10(d)] codes 97010 through 97039) should only be performed in conjunction with other active treatments. Although these modalities are occasionally useful in the postsurgical physical medicine period, their use should be minimized in favor of active physical rehabilitation and independent self-management. (d) Postsurgical Physical Medicine Treatment Recommendations (1) The postsurgical physical medicine treatment recommendations, as listed below, indicate frequency and duration of postsurgical treatment for specific surgeries. The specified surgeries in these guidelines are not all inclusive. Requests for postsurgical physical medicine treatment not included in these guidelines shall be considered pursuant to section 9792.21(d)(1). The physical medicine treatment recommendations (listed alphabetically) are adapted from the Official Disability Guidelines (ODG) except where developed by the Division of Workers' Compensation and indicated as [DWC]. The postsurgical physical medicine period is identified by an asterisk [*] as developed by DWC. Postsurgical Treatment Guidelines Ankle & Foot Ankle & Foot Exercise program goals should include strength, flexibility, endurance, coordination, and education. Patients can be advised to do early passive range-of-motion exercises at home by a therapist. (Colorado, 2001) (Aldridge, 2004) This RCT (randomized controlled trial) supports early motion (progressing to full weight-bearing at 8 weeks from treatment) as an acceptable form of rehabilitation in surgically treated patients with Achilles tendon ruptures. (Twaddle, 2007) Achilles tendon rupture (ICD9 727.67): Postsurgical treatment: 48 visits over 16 weeks *Postsurgical physical medicine treatment period: 6 months Ankle Sprain (ICD9 845.0): Postsurgical treatment: 34 visits over 16 weeks *Postsurgical physical medicine treatment period: 6 months Anterior tibial tendon [DWC]: Postsurgical treatment: 8 visits over 3 months *Postsurgical physical medicine treatment period: 6 months Amputation of foot (ICD9 896): Post-replantation surgery: 48 visits over 26 weeks *Postsurgical physical medicine treatment period: 12 months Post-amputation treatment [DWC]: 48 visits over 26 weeks *Postsurgical physical medicine treatment period: 12 months Amputation of toe (ICD9 895): Post-replantation surgery: 20 visits over 12 weeks *Postsurgical physical medicine treatment period: 6 months Dislocation of the peroneal tendons [DWC]: Postsurgical treatment: 8 visits over 3 months *Postsurgical physical medicine treatment period: 6 months Enthesopathy of ankle and tarsus (ICD9 726.7): Postsurgical treatment: 9 visits over 8 weeks *Postsurgical physical medicine treatment period: 4 months Fracture of ankle (ICD9 824): Postsurgical treatment: 21 visits over 16 weeks *Postsurgical physical medicine treatment period: 6 months Fracture of ankle, Bimalleolar (ICD9 824.4): Postsurgical treatment (ORIF): 21 visits over 16 weeks *Postsurgical physical medicine treatment period: 6 months Postsurgical treatment (arthrodesis): 21 visits over 16 weeks *Postsurgical physical medicine treatment period: 6 months Fracture of ankle, Trimalleolar (ICD9 824.6): Postsurgical treatment: 21 visits over 16 weeks *Postsurgical physical medicine treatment period: 6 months Fracture of one or more phalanges of foot (ICD9 826): Postsurgical treatment: 12 visits over 12 weeks *Postsurgical physical medicine treatment period: 6 months Special Consideration [DWC]: Postsurgical physical medicine is rarely needed for ganglionectomy. Fracture of tibia and fibula (ICD9 823): Postsurgical treatment (ORIF): 30 visits over 12 weeks *Postsurgical physical medicine treatment period: 6 months Hallux rigidus (ICD9 735.2): Postsurgical treatment: 9 visits over 8 weeks *Postsurgical physical medicine treatment period: 4 months Hallux valgus (ICD9 735.0): Postsurgical treatment: 9 visits over 8 weeks *Postsurgical physical medicine treatment period: 4 months Hallux varus (ICD9 735.1): Postsurgical treatment: 9 visits over 8 weeks *Postsurgical physical medicine treatment period: 4 months Metatarsal stress fracture (ICD9 825): Postsurgical treatment: 21 visits over 16 weeks *Postsurgical physical medicine treatment period: 6 months Other hammer toe (ICD9 735.4): Postsurgical treatment: 9 visits over 8 weeks *Postsurgical physical medicine treatment period: 4 months Peroneal tendon repair [DWC]: Postsurgical treatment: 8 visits over 3 months *Postsurgical physical medicine treatment period: 6 months Posterior tibial tendonitis [DWC]: Postsurgical treatment: 8 visits over 3 months *Postsurgical physical medicine treatment period: 6 months Posterior tibial tenosynovitis (partial or complete rupture) [DWC]: Postsurgical treatment: 8 visits over 3 months *Postsurgical physical medicine treatment period: 6 months Burns Recommended. Occupational therapy and physical therapy for the patient with burns may include respiratory management, edema management, splinting and positioning, physical function (mobility, function, exercise), scar management, and psychosocial elements. (Simons, 2003) As with any treatment, if there is no improvement after 2-3 weeks the protocol may be modified or re-evaluated. Burns (ICD9 949): Postsurgical treatment: 16 visits over 8 weeks *Postsurgical physical medicine treatment period: 6 months Cardiopulmonary [DWC]: Coronary Stenting [DWC]: Postsurgical treatment: 36 visits over 18 weeks *Postsurgical physical medicine treatment period: 6 months Heart Valve repair/replacement [DWC]: Postsurgical treatment: 36 visits over 18 weeks *Postsurgical physical medicine treatment period: 6 months Percutaneous transluminal coronary angioplasty (PTCA) [DWC]: Postsurgical treatment: 36 visits over 18 weeks *Postsurgical physical medicine treatment period: 6 months Carpal Tunnel Syndrome Recommended as indicated below. There is limited evidence demonstrating the effectiveness of PT (physical therapy) or OT (occupational therapy) for CTS (carpal tunnel syndrome). The evidence may justify 3 to 5 visits over 4 weeks after surgery, up to the maximums shown below. Benefits need to be documented after the first week, and prolonged therapy visits are not supported. Carpal tunnel syndrome should not result in extended time off work while undergoing multiple therapy visits, when other options (including surgery for carefully selected patients) could result in faster return to work. Furthermore, carpal tunnel release surgery is a relatively simple operation that also should not require extended multiple therapy office visits for recovery. Of course, these statements do not apply to cases of failed surgery and/or misdiagnosis (e.g., CRPS (complex regional pain syndrome) I instead of CTS). (Feuerstein, 1999) (O'Conner-Cochrane, 2003) (Verhagen-Cochrane, 2004) (APTA, 2006) (Bilic, 2006) Post surgery, a home therapy program is superior to extended splinting. (Cook, 1995) Continued visits should be contingent on documentation of objective improvement, i.e., VAS (visual analog scale) improvement greater than four, and long-term resolution of symptoms. Therapy should include education in a home program, work discussion and suggestions for modifications, lifestyle changes, and setting realistic expectations. Passive modalities, such as heat, iontophoresis, phonophoresis, ultrasound and electrical stimulation, should be minimized in favor of active treatments. Carpal tunnel syndrome (ICD9 354.0): Postsurgical treatment (endoscopic): 3-8 visits over 3-5 weeks *Postsurgical physical medicine treatment period: 3 months Postsurgical treatment (open): 3-8 visits over 3-5 weeks *Postsurgical physical medicine treatment period: 3 months Elbow & Upper Arm Arthropathy, unspecified (ICD9 716.9): Postsurgical treatment, arthroplasty, elbow: 24 visits over 8 weeks *Postsurgical physical medicine treatment period: 4 months Cubital tunnel release [DWC]: Postsurgical treatment: 20 visits over 3 months *Postsurgical physical medicine treatment period: 6 months Dislocation of elbow (ICD9 832): Unstable dislocation, postsurgical treatment: 10 visits over 9 weeks *Postsurgical physical medicine treatment period: 4 months ECRB / ECRL debridement [DWC]: Postsurgical treatment: 10 visits over 4 months *Postsurgical physical medicine treatment period: 6 months ECRB / ECCRL tenotomy [DWC]: Postsurgical treatment: 10 visits over 4 months *Postsurgical physical medicine treatment period: 6 months Elbow diagnostic arthroscopy and arthroscopic debridement [DWC]: Postsurgical treatment: 20 visits over 2 months *Postsurgical physical medicine treatment period: 4 months Elbow collateral ligament repair [DWC]: Postsurgical treatment: 14 visits over 6 months *Postsurgical physical medicine treatment period: 8 months Enthesopathy of elbow region (ICD9 726.3): Postsurgical treatment: 12 visits over 12 weeks *Postsurgical physical medicine treatment period: 6 months Fracture of humerus (ICD9 812): Postsurgical treatment: 24 visits over 14 weeks *Postsurgical physical medicine treatment period: 6 months Fracture of radius/ulna (ICD9 813): Postsurgical treatment: 16 visits over 8 weeks *Postsurgical physical medicine treatment period: 4 months Lateral epicondylitis/Tennis elbow (ICD9 726.32): Postsurgical treatment: 12 visits over 12 weeks *Postsurgical physical medicine treatment period: 6 months Medial epicondylitis/Golfers' elbow (ICD9 726.31): Postsurgical treatment: 12 visits over 12 weeks *Postsurgical physical medicine treatment period: 6 months Muscle or tendon transfers for elbow flexion [DWC]: Postsurgical treatment: 30 visits over 5 months *Postsurgical physical medicine treatment period: 8 months Rupture of biceps tendon (ICD9 727.62): Postsurgical treatment: 24 visits over 16 weeks *Postsurgical physical medicine treatment period: 6 months Sprains and strains of elbow and forearm (ICD9 841): Postsurgical treatment/ligament repair: 24 visits over 16 weeks *Postsurgical physical medicine treatment period: 6 months Traumatic amputation of arm (ICD9 887): Post-amputation treatment: without complications, no prosthesis [DWC]: 18 visits over 4 months *Postsurgical physical medicine treatment period: 6 months Post-amputation treatment: without complications, with prosthesis [DWC]: 30 visits over 6 months *Postsurgical physical medicine treatment period: 9 months Post-amputation treatment: with complications, no prosthesis [DWC]: 30 visits over 5 months *Postsurgical physical medicine treatment period: 7 months Post-amputation treatment: with complications and prosthesis [DWC]: 40 visits over 8 months *Postsurgical physical medicine treatment period: 12 months Post-replantation surgery: 48 visits over 26 weeks *Postsurgical physical medicine treatment period: 12 months Triceps repair [DWC]: Postsurgical treatment: 24 visits over 4 months *Postsurgical physical medicine treatment period: 6 months Ulnar nerve entrapment/Cubital tunnel syndrome (ICD9 354.2): Postsurgical treatment: 20 visits over 10 weeks *Postsurgical physical medicine treatment period: 6 months Forearm, Wrist, & Hand (Not including Carpal Tunnel Syndrome - see separate post surgical guideline.) Used after surgery and amputation. During immobilization, there was weak evidence of improved hand function in the short term, but not in the longer term, for early occupational therapy, and of a lack of differences in outcome between supervised and unsupervised exercises. Post-immobilization, there was weak evidence of a lack of clinically significant differences in outcome in patients receiving formal rehabilitation therapy, passive mobilization or whirlpool immersion compared with no intervention. There was weak evidence of a short-term benefit of continuous passive motion (post external fixation), intermittent pneumatic compression and ultrasound. There was weak evidence of better short-term hand function in patients given therapy than in those given instructions for home exercises by a surgeon. (Handoll-Cochrane, 2002) (Handoll-Cochrane, 2006) Amputation of arm, below the elbow [DWC]: Post-amputation treatment: without complications, no prosthesis: 18 visits over 4 months *Postsurgical physical medicine treatment period: 6 months Post-amputation: without complications, with prosthesis: 30 visits over 6 months *Postsurgical physical medicine treatment period: 9 months Post-amputation: with complications, no prosthesis: 30 visits over 5 months *Postsurgical physical medicine treatment period: 7 months Post-amputation: with complications and prosthesis: 40 visits over 8 months *Postsurgical physical medicine treatment period: 12 months Amputation of hand (ICD9 887): Post-amputation treatment: without complications, no prosthesis [DWC]: 18 visits over 4 months *Postsurgical physical medicine treatment period: 6 months Post-amputation treatment: with complications, no prosthesis [DWC]: 24 visits over 5 months *Postsurgical physical medicine treatment period: 7 months Post-replantation surgery: 48 visits over 26 weeks *Postsurgical physical medicine treatment period: 12 months Amputation of thumb; finger (ICD9 885; 886): Post-replantation surgery: 36 visits over 12 weeks *Postsurgical physical medicine treatment period: 6 months Post-amputation: Amputation of fingers without replantation [DWC]: 14 visits over 3 months *Postsurgical physical medicine treatment period: 6 months Post-amputation: Amputation of thumb without replantation [DWC]: 16 visits over 3 months *Postsurgical physical medicine treatment period: 6 months Arthropathy, unspecified (ICD9 716.9): Postsurgical treatment, arthroplasty/fusion, wrist/finger: 24 visits over 8 weeks *Postsurgical physical medicine treatment period: 4 months Contracture of palmar fascia (Dupuytren's) (ICD9 728.6): Postsurgical treatment: 12 visits over 8 weeks *Postsurgical physical medicine treatment period: 4 months Digital nerve repair [DWC]: Postsurgical treatment: 8 visits over 4 months *Postsurgical physical medicine treatment period: 6 months DIP joint intraarticular fracture at middle or distal phalanx [DWC]: Postsurgical treatment: 14 visits over 4 months *Postsurgical physical medicine treatment period: 6 months Dislocation of finger (ICD9 834): Postsurgical treatment: 16 visits over 10 weeks *Postsurgical physical medicine treatment period: 4 months Dislocation of wrist (ICD9 833): Postsurgical treatment (TFCC reconstruction): 16 visits over 10 weeks *Postsurgical physical medicine treatment period: 4 months Extensor tendon repair or tenolysis [DWC]: Postsurgical treatment: 18 visits over 4 months *Postsurgical physical medicine treatment period: 6 months Extensor tenosynovectomy [DWC]: Postsurgical treatment: 14 visits over 3 months *Postsurgical physical medicine treatment period: 6 months Flexor tendon repair or tenolysis Zone 2 and other than Zone 2 [DWC]: Postsurgical treatment: Flexor tendon repair or tenolysis Zone 2: 30 visits over 6 months *Postsurgical physical medicine treatment period: 8 months Postsurgical treatment: Other than Zone 2: 20 visits over 3 months *Postsurgical physical medicine treatment period: 6 months Flexor tenosynovectomy [DWC]: Postsurgical treatment: 14 visits over 3 months *Postsurgical physical medicine treatment period: 6 months Flexor tendon repair (forearm) [DWC]: Postsurgical treatment: 12 visits over 4 months *Postsurgical physical medicine treatment period: 6 months Fracture of carpal bone (wrist) (ICD9 814): Postsurgical treatment: 16 visits over 10 weeks *Postsurgical physical medicine treatment period: 4 months Fracture of metacarpal bone (hand) (ICD9 815): Postsurgical treatment: 16 visits over 10 weeks *Postsurgical physical medicine treatment period: 4 months Fracture of one or more phalanges of hand (fingers) (ICD9 816): Postsurgical treatment: Complicated, 16 visits over 10 weeks *Postsurgical physical medicine treatment period: 4 months Fracture of radius/ulna (forearm) (ICD9 813): Postsurgical treatment: 16 visits over 8 weeks *Postsurgical physical medicine treatment period: 4 months Ganglion and cyst of synovium, tendon, and bursa (ICD9 727.4): Postsurgical treatment: 18 visits over 6 weeks *Special Consideration: Postsurgical physical medicine is rarely needed for ganglionectomy. Intersection syndrome [DWC]: Postsurgical treatment: 9 visits over 3 months *Postsurgical physical medicine treatment period: 6 months Median Nerve Repair: Forearm - Wrist [DWC]: Postsurgical treatment: 20 visits over 6 weeks *Postsurgical physical medicine treatment period: 6 months PIP and MCP capsulotomy/capsulectomy [DWC]:  HTMLCONTROL Forms.HTML:Hidden.1  Postsurgical treatment: 24 visits over 2 months *Postsurgical physical medicine treatment period: 4 months PIP and MCP collateral ligament reconstruction [DWC]: Postsurgical treatment: 18 visits over 4 months *Postsurgical physical medicine treatment period: 6 months PIP and MCP collateral ligament repairs [DWC]: Postsurgical treatment: 12 visits over 4 months *Postsurgical physical medicine treatment period: 6 months PIP joint intraarticular fracture and or dislocation at proximal or middle phalanx [DWC]: Postsurgical treatment: Postsurgical treatment: 20 visits over 6 months *Postsurgical physical medicine treatment period: 8 months Proximal row carpectomy [DWC]: Postsurgical treatment:20 visits over 6 months *Postsurgical physical medicine treatment period: 8 months Nerve Repair: Elbow - Wrist [DWC] Postsurgical treatment: 20 visits over 6 weeks *Postsurgical physical medicine treatment period: 8 months Radial styloid tenosynovitis (de Quervain's) (ICD9 727.04): Postsurgical treatment: 14 visits over 12 weeks *Postsurgical physical medicine treatment period: 6 months Sprains and strains of elbow and forearm (ICD9 841): Post-surgical treatment/ligament repair: 24 visits over 16 weeks *Postsurgical physical medicine treatment period: 6 months Synovitis and tenosynovitis (ICD9 727.0): Postsurgical treatment: 14 visits over 12 weeks *Postsurgical physical medicine treatment period: 6 months Tendon transfer forearm, wrist or hand [DWC]: Postsurgical treatment: 14 visits over 4 months *Postsurgical physical medicine treatment period: 6 months Tendon transfers - thumb or finger [DWC]: Postsurgical treatment: 26 visits over 4 months *Postsurgical physical medicine treatment period: 6 months TFCC injuries-debridement (arthroscopic) [DWC]: Postsurgical treatment:10 visits over 10 weeks *Postsurgical physical medicine treatment period: 4 months Trigger finger (ICD9 727.03): Postsurgical treatment: 9 visits over 8 weeks *Postsurgical physical medicine treatment period: 4 months Ulnar nerve entrapment/Cubital tunnel syndrome (ICD9 354.2): Postsurgical treatment: 20 visits over 10 weeks *Postsurgical physical medicine treatment period: 6 months Wrist - intercarpal ligament reconstruction or repair [DWC]: Postsurgical treatment 20 visits over 6 months *Postsurgical physical medicine treatment period: 8 months Head Patient rehabilitation after traumatic brain injury is divided into two periods: acute and subacute. In the beginning of rehabilitation therapist evaluates patient's functional status, later he uses methods and means of treatment, and evaluates effectiveness of rehabilitation. Early ambulation is very important for patients with coma. Therapy consists of prevention of complications, improvement of muscle force, and range of motions, balance, movement coordination, endurance and cognitive functions. Early rehabilitation is necessary for traumatic brain injury patients and use of therapy methods can help to regain lost functions and to come back to the society. (Colorado, 2005) (Brown, 2005) (Franckeviciute, 2005) (Driver, 2004) (Shiel, 2001) Fracture of skull (ICD9 801): Postsurgical treatment: 34 visits over 16 weeks *Postsurgical physical medicine treatment period: 6 months Hernia Not recommended. No evidence of successful outcomes compared to surgery. Hip, Pelvis and Thigh (femur) A therapy program that starts immediately following hip surgery allows for greater improvement in muscle strength, walking speed and functional score. (Jan, 2004) (Jain, 2002) (Penrod, 2004) (Tsauo, 2005) (Brigham, 2003) (White, 2005) (National, 2003) A weight-bearing exercise program can improve balance and functional ability to a greater extent than a non-weight-bearing program. (Expert, 2004) (Binder, 2004) (Bolgla, 2005) (Handoll, 2004) (Kuisma, 2002) (Lauridsen, 2002) (Mangione, 2005) (Sherrington, 2004) Patients with hip fracture should be offered a coordinated multidisciplinary rehabilitation program with the specific aim of regaining sufficient function to return to their pre-fracture living arrangements. (Cameron, 2005) Accelerated perioperative care and rehabilitation intervention after hip and knee arthroplasty (including intense therapy and exercise) reduced mean hospital length of stay (LOS) from 8.8 days before implementation to 4.3 days after implementation. (Larsen, 2008) Arthrodesis [DWC]: Postsurgical treatment: 22 visits over 3 months *Postsurgical physical medicine treatment period: 6 months Arthropathy, unspecified (ICD9 716.9): Postsurgical treatment, arthroplasty/fusion, hip: 24 visits over 10 weeks *Postsurgical physical medicine treatment period: 4 months Fracture of neck of femur (ICD9 820): Postsurgical treatment: 24 visits over 10 weeks *Postsurgical physical medicine treatment period: 4 months Fracture of pelvis (ICD9 808): Postsurgical treatment: 24 visits over 10 weeks *Postsurgical physical medicine treatment period: 4 months Osteoarthrosis and allied disorders (ICD9 715): Post-surgical treatment: 18 visits over 12 weeks *Postsurgical physical medicine treatment period: 6 months Synovectomy [DWC]: Postsurgical treatment: 14 visits over 3 months *Postsurgical physical medicine treatment period: 6 months Knee Controversy exists about the effectiveness of therapy after arthroscopic partial meniscectomy. (Goodwin, 2003) Functional exercises after hospital discharge for total knee arthroplasty result in a small to moderate short-term, but not long-term, benefit. In the short term therapy interventions with exercises based on functional activities may be more effective after total knee arthroplasty than traditional exercise programs, which concentrate on isometric muscle exercises and exercises to increase range of motion in the joint. (Minns Lowe, 2007) Accelerated perioperative care and rehabilitation intervention after hip and knee arthroplasty (including intense therapy and exercise) reduced mean hospital length of stay (LOS) from 8.8 days before implementation to 4.3 days after implementation. (Larsen, 2008) Amputation of leg (ICD9 897): Post-replantation surgery: 48 visits over 26 weeks *Postsurgical physical medicine treatment period: 12 months Post-amputation [DWC]: 48 visits over 6 months *Postsurgical physical medicine treatment period: 8 months Arthritis (Arthropathy, unspecified) (ICD9 716.9): Postsurgical treatment, arthroplasty, knee: 24 visits over 10 weeks *Postsurgical physical medicine treatment period: 4 months Dislocation of knee; Tear of medial/lateral cartilage/meniscus of knee; Dislocation of patella (ICD9 836; 836.0; 836.1; 836.2; 836.3; 836.5): Postsurgical treatment: (Meniscectomy): 12 visits over 12 weeks *Postsurgical physical medicine treatment period: 6 months Fracture of neck of femur (ICD9 820): Postsurgical treatment: 18 visits over 8 weeks *Postsurgical physical medicine treatment period: 6 months Fracture of other and unspecified parts of femur (ICD9 821): Postsurgical treatment: 30 visits over 12 weeks *Postsurgical physical medicine treatment period: 6 months Fracture of patella (ICD9 822): Postsurgical treatment: 10 visits over 8 weeks *Postsurgical physical medicine treatment period: 4 months Fracture of tibia and fibula (ICD9 823): Postsurgical treatment (ORIF): 30 visits over 12 weeks *Postsurgical physical medicine treatment period: 6 months Manipulation under Anesthesia (knee) [DWC]: Postsurgical treatment: 20 visits over 4 months *Postsurgical physical medicine treatment period: 6 months Old bucket handle tear; Derangement of meniscus; Loose body in knee; Chondromalacia of patella; Tibialis tendonitis (ICD9 717.0; 717.5; 717.6; 717.7; 726.72): Postsurgical treatment: 12 visits over 12 weeks *Postsurgical physical medicine treatment period: 4 months Sprains and strains of knee and leg; Cruciate ligament of knee (ACL tear) (ICD9 844; 844.2): Postsurgical treatment: (ACL repair): 24 visits over 16 weeks *Postsurgical physical medicine treatment period: 6 months Low Back As compared with no therapy, therapy (up to 20 sessions over 12 weeks) following disc herniation surgery was effective. Because of the limited benefits of therapy relative to massage, it is open to question whether this treatment acts primarily physiologically, but psychological factors may contribute substantially to the benefits observed. (Erdogmus, 2007) Artificial Disc [DWC]: Postsurgical treatment: 18 visits over 4 months *Postsurgical physical medicine treatment period: 6 months Fracture of vertebral column with spinal cord injury (ICD9 806): Postsurgical treatment: 48 visits over 18 weeks *Postsurgical physical medicine treatment period: 6 months Fracture of vertebral column without spinal cord injury (ICD9 805): Postsurgical treatment: 34 visits over 16 weeks *Postsurgical physical medicine treatment period: 6 months Intervertebral disc disorder with myelopathy (ICD9 722.7): Postsurgical treatment: 48 visits over 18 weeks *Postsurgical physical medicine treatment period: 6 months Intervertebral disc disorders without myelopathy (ICD9 722.1; 722.2; 722.5; 722.6; 722.8): Postsurgical treatment (discectomy/laminectomy): 16 visits over 8 weeks *Postsurgical physical medicine treatment period: 6 months Postsurgical treatment (arthroplasty): 26 visits over 16 weeks *Postsurgical physical medicine treatment period: 6 months Postsurgical treatment (fusion): 34 visits over 16 weeks *Postsurgical physical medicine treatment period: 6 months Spinal stenosis (ICD9 724.0): See 722.1 for postsurgical visits *Postsurgical physical medicine treatment period: 6 months Neck & Upper Back Displacement of cervical intervertebral disc (ICD9 722.0): Postsurgical treatment (discectomy/laminectomy): 16 visits over 8 weeks *Postsurgical physical medicine treatment period: 6 months Postsurgical treatment (fusion, after graft maturity): 24 visits over 16 weeks *Postsurgical physical medicine treatment period: 6 months Degeneration of cervical intervertebral disc (ICD9 722.4): See 722.0 for postsurgical visits *Postsurgical physical medicine treatment period: 6 months Fracture of vertebral column without spinal cord injury (ICD9 805): Postsurgical treatment: 34 visits over 16 weeks *Postsurgical physical medicine treatment period: 6 months Fracture of vertebral column with spinal cord injury (ICD9 806): Postsurgical treatment: 48 visits over 18 weeks *Postsurgical physical medicine treatment period: 6 months Shoulder Acromioclavicular joint dislocation (ICD9 831.04): AC separation, type III+: 8 visits over 8 weeks *Postsurgical physical medicine treatment period: 6 months Adhesive capsulitis (ICD9 726.0): Postsurgical treatment: 24 visits over 14 weeks *Postsurgical physical medicine treatment period: 6 months Arthritis (Osteoarthrosis; Rheumatoid arthritis; Arthropathy, unspecified) (ICD9 714.0; 715; 715.9; 716.9): Postsurgical treatment, arthroplasty, shoulder: 24 visits over 10 weeks *Postsurgical physical medicine treatment period: 6 months Brachial plexus lesions (Thoracic outlet syndrome) (ICD9 353.0): Postsurgical treatment: 20 visits over 10 weeks *Postsurgical physical medicine treatment period: 6 months Complete rupture of rotator cuff (ICD9 727.61; 727.6): Postsurgical treatment: 40 visits over 16 weeks *Postsurgical physical medicine treatment period: 6 months Dislocation of shoulder (ICD9 831): Postsurgical treatment (Bankart): 24 visits over 14 weeks *Postsurgical physical medicine treatment period: 6 months Fracture of humerus (ICD9 812): Postsurgical treatment: 24 visits over 14 weeks *Postsurgical physical medicine treatment period: 6 months Rotator cuff syndrome/Impingement syndrome (ICD9 726.1; 726.12): Postsurgical treatment, arthroscopic: 24 visits over 14 weeks *Postsurgical physical medicine treatment period: 6 months Postsurgical treatment, open: 30 visits over 18 weeks *Postsurgical physical medicine treatment period: 6 months Sprained shoulder; rotator cuff (ICD9 840; 840.4): Postsurgical treatment (RC repair/acromioplasty): 24 visits over 14 weeks *Postsurgical physical medicine treatment period: 6 months (2) Appendix C - Postsurgical Treatment Guidelines Evidence-Based Reviews (May, 2009)- is incorporated by reference into the MTUS as supplemental part of the Postsurgical Treatment Guidelines. A copy of Appendix C may be obtained from the Medical Unit, Division of Workers' Compensation, P.O. Box 71010, Oakland, CA 94612-1486, or from the DWC web site at  HYPERLINK "http://www.dwc.ca.gov" http://www.dwc.ca.gov. (3) Appendix E - Postsurgical Treatment Guidelines Work Loss Data Institute-Official Disability Guidelines References (May, 2009) - is incorporated by reference into the MTUS as supplemental part of the Postsurgical Treatment Guidelines. A copy of Appendix E may be obtained from the Medical Unit, Division of Workers' Compensation, P.O. Box 71010, Oakland, CA 94612-1486, or from the DWC web site at  HYPERLINK "http://www.dwc.ca.gov" http://www.dwc.ca.gov. Note: Authority cited: Sections 133, 4603.5, 5307.3 and 5307.27, Labor Code. Reference: Sections 77.5, 4600, 4604.5 and 5307.27, Labor Code. 9792.24.4. Opioids Treatment Guidelines. (a) The Opioids Treatment Guidelines (July 2016) consisting of two parts, is entitled The Guideline for the Use of Opioids to Treat Work-Related Injuries, and is adopted and incorporated by reference into the MTUS. Part 1 contains the executive summary, abbreviated treatment protocols, background information, complete recommendations, and appendices with useful tools for clinicians. Part 2 contains supplemental information consisting of a discussion of the medical evidence supporting the recommendations and a summary of recommendations from other guidelines that were reviewed. These guidelines replace the existing parts of the MTUS that refer to opioid use. A copy of the Opioids Treatment Guidelines may be obtained from the Medical Unit, Division of Workers' Compensation, P.O. Box 71010, Oakland, CA 94612-1486, or from the DWC web site at  HYPERLINK "http://www.dwc.ca.gov" http://www.dwc.ca.gov. The Administrative Director adopts and incorporates by reference the Opioids Guideline (ACOEM April 20, 2017) into the MTUS from the ACOEM Practice Guidelines. (b) The Opioids Treatment Guidelines describes the appropriate use of opioid medications as part of an overall multidisciplinary treatment regimen for acute, sub-acute, post-operative, and chronic non-cancer pain. Thisese guidelines appliesy when the use of opioid medications is being considered as part of the treatment regimen. Note: Authority cited: Sections 133, 4603.5 and 5307.27, Labor Code. Reference: Sections 77.5, 4600, 4604.5 and 5307.27, Labor Code. ADDENDUM TWO TO ADMINISTRATIVE DIRECTOR ORDER [Effective for services on or after XXXX, 2017] ACOEM Guidelines adopted and incorporated by reference HYPERLINK "http://www.dir.ca.gov/dwc/MTUS/ACOEM-Guidelines/Initial-Approaches-to-Treatment-Guideline.pdf"Initial Approaches to Treatment Guideline (ACOEM June 30, 2017) HYPERLINK "http://www.dir.ca.gov/dwc/MTUS/ACOEM-Guidelines/Cervical-and-Thoracic-Spine-Disorders-Guideline.pdf"Cervical and Thoracic Spine Disorders Guideline (ACOEM May 27, 2016) HYPERLINK "http://www.dir.ca.gov/dwc/MTUS/ACOEM-Guidelines/Shoulder-Disorders-Guideline.pdf"Shoulder Disorders Guideline (ACOEM August 1, 2016) HYPERLINK "http://www.dir.ca.gov/dwc/MTUS/ACOEM-Guidelines/Elbow-Disorders-Guideline.pdf"Elbow Disorders Guideline (ACOEM 2013) HYPERLINK "http://www.dir.ca.gov/dwc/MTUS/ACOEM-Guidelines/Hand-Wrist-and-Forearm-Disorders-Guideline.pdf"Hand, Wrist, and Forearm Disorders Guideline (ACOEM June 30, 2016) HYPERLINK "http://www.dir.ca.gov/dwc/MTUS/ACOEM-Guidelines/Low-Back-Disorders-Guideline.pdf"Low Back Disorders Guideline (ACOEM February 24, 2016) HYPERLINK "http://www.dir.ca.gov/dwc/MTUS/ACOEM-Guidelines/Knee-Disorders-Guideline.pdf"Knee Disorders Guideline (ACOEM October 28, 2015) HYPERLINK "http://www.dir.ca.gov/dwc/MTUS/ACOEM-Guidelines/Ankle-and-Foot-Disorders-Guideline.pdf"Ankle and Foot Disorders Guideline (ACOEM September 2015) HYPERLINK "http://www.dir.ca.gov/dwc/MTUS/ACOEM-Guidelines/Eye-Disorders-Guideline.pdf"Eye Disorders Guideline (ACOEM April 1, 2017) HYPERLINK "http://www.dir.ca.gov/dwc/MTUS/ACOEM-Guidelines/Hip-and-Groin-Disorders-Guideline.pdf"Hip and Groin Guideline (ACOEM May 1, 2011) HYPERLINK "http://www.dir.ca.gov/dwc/MTUS/ACOEM-Guidelines/Occupational-Work-Related-Asthma-Guideline.pdf"Occupational/Work-Related Asthma Medical Treatment Guideline (ACOEM January 4, 2016)  HYPERLINK "http://www.dir.ca.gov/dwc/MTUS/ACOEM-Guidelines/Occupational-Interstitial-Lung-Disease-Guideline.pdf" Occupational Interstitial Lung Disease Guideline (ACOEM January 4, 2016) HYPERLINK "http://www.dir.ca.gov/dwc/MTUS/ACOEM-Guidelines/Chronic-Pain-Guideline.pdf"Chronic Pain Guideline (ACOEM May 15, 2017) HYPERLINK "http://www.dir.ca.gov/dwc/MTUS/ACOEM-Guidelines/Opioids-Guideline.pdf"Opioids Guideline (ACOEM April 20, 2017)     [Proposed] Order of the Acting Administrative Director Evidence-Based Updates to the Medical Treatment Utilization Schedule California Code of Regulations, title 8, sections 9792.20 9792.26 (MTUS) (30-Day Comment Period August 2017) Z[\]gh 5 L N O z  , ĴznbVbVbVbJVbVbh 3CJOJQJaJh ^CJOJQJaJh[ BCJOJQJaJh7tlCJOJQJaJhzhPW5CJOJQJaJh5CJOJQJaJhI hI 5CJOJQJaJh}$5CJOJQJaJhzh}$5CJOJQJaJh7tl5CJOJQJaJ,jh9Iph9IpCJOJQJUmHnHuht4CJOJQJaJhI CJOJQJaJ7YZ\] M N O 0 $a$gdJ# $da$gdk $da$gdI $a$gdI , O V W {    G N U k l x 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