7 Colo. Code Regs. § 1101-3-17-08-8
Recommendation 83. Injections containing only anesthesia, also called selective nerve blocks, are acceptable for diagnostic purposes to identify pain generators or pathology.
Recommendation 84. Imaging guidance for anesthesia-only injections using sonography or fluoroscopy is acceptable.
Recommendation 85. Distension arthrography or brisement is acceptable for post-traumatic stiff shoulder when all of the following parameters are met:
* the condition is refractory to at least 3 months of conservative care emphasizing Active Therapies as outlined in Section 7.a.i.; and
* range of motion remains significantly restricted; and
* early therapy to maintain range of motion and to restore strength and function follows distension arthrography.
Recommendation 86. An initial steroid injection is acceptable. They may target the subacromial space, glenohumeral joint, acromioclavicular (AC) joint, biceps tendon sheath, subdeltoid bursa, subcoracoid space, or around the suprascapular nerve.
Recommendation 87. Steroid injections beyond the first one are acceptable given the following parameters:
* There is documentation of functional improvement from the previous injection.
* Injections are at least 4 weeks apart.
* The maximum is 4 injections per year for all sites combined.
Recommendation 88. Imaging guidance for glucocorticosteroid injections using sonography or fluoroscopy is acceptable.
Recommendation 89. Viscosupplementation is acceptable for glenohumeral arthritis in the absence of other symptomatic shoulder pathology within all of the following parameters:
* the condition limits function and is unresponsive to at least 6 weeks of conservative care emphasizing Active Therapies as outlined in Section 7.a.i.; and
* each course of treatment is at least 6 months apart. The number of injections in each course depends on the product used.
Recommendation 90. Viscosupplementation is not recommended for any of the following:
* rotator cuff tendinopathy, or
* adhesive capsulitis, or
* subacromial impingement syndrome.
Recommendation 91. Prior authorization is required for ultrasound-guided needle lavage and aspiration for patients with calcific tendonitis who have not responded to conservative care emphasizing Active Therapies as outlined in Section 7.a.i.
Recommendation 92. Platelet-rich plasma injections are generally not recommended. They are acceptable when all of the following parameters are met:
* there is tendon damage; and
* the condition is not responding to at least 6 weeks of conservative care emphasizing Active Therapies as outlined in Section 7.a.i; and
* the next level of guideline-consistent therapy would involve an invasive procedure with risk of significant complications.
Recommendation 93. Platelet-rich plasma injections beyond the first one are acceptable when all of the following parameters are met:
* there is documentation of significant functional benefit from the previous injection; and
* the patient has not returned to full function or full duty at work; and
* the injections are at least 4 weeks apart.
* The maximum is 1 repeat injection.
Recommendation 94. Prolotherapy and sclerotherapy are not recommended.
Recommendation 95. Stem cell injections are not recommended. These include but are not limited to mesenchymal, adipose-derived, amniotic, and bone marrow-derived stem cells.
Recommendation 96. Trigger point injections are acceptable when all of the following parameters are met:
* there are consistent, well-circumscribed trigger points with a local twitch response; and
* there is a characteristic radiation of pain pattern and local autonomic reaction (e.g., persistent hyperemia following palpation); and
* trigger points are not responding to specific, noninvasive, myofascial interventions within a 6-week time frame; and
* concurrent participation in Active Therapies as outlined in Section 7.a.i. is required; and
* the maximum frequency is 1 session per week, with a maximum of 4 injections per session; and
* the maximum duration is 8 weeks. Beyond 8 weeks, refer to the Chronic Pain Disorder Medical Treatment Guidelines (MTGs).
Recommendation 97. Sedation is not recommended for patients receiving trigger point injections.
Recommendation 98. The inclusion of a surgical intervention as acceptable does not imply that every patient meeting the Medical Treatment Guideline (MTG) criteria must or should have that surgery. It means that for individuals meeting the criteria, the surgery should be approved when the treating surgeon and patient decide to proceed with it.
Recommendation 99. With the exception of conditions requiring urgent surgery, referral for surgical evaluation is indicated when the criteria listed for specific surgeries are met, along with all of the following criteria:
* symptomatic and functional improvement has plateaued with continued functional impairment that interferes with return to work and/or participation in active therapy; and
* findings on advanced imaging correlate with clinical findings to confirm a specific diagnosis; and
* confounding psychological or physical conditions that may respond to non-surgical techniques but may be refractory to surgical intervention have been diagnostically eliminated; and
* the expected functional outcome following surgery is better than that of non-operative management and outweighs the risk of harm.
Recommendation 100. Urgent surgical stabilization and ligament reconstruction is acceptable for acromioclavicular (AC) joint separations of Rockwood classification Type IV or above.
Recommendation 101. Stabilization and ligament reconstruction is acceptable for Rockwood Type III acromioclavicular (AC) joint separations following failure of 3 months of conservative care emphasizing Active Therapies as outlined in Section 7.a.i. For patients with particularly high physical demands on their shoulder, orthopedic consultation with surgical intervention as early as two weeks from the date of injury may be considered.
Recommendation 102. Stabilization and ligament reconstruction is not recommended for acromioclavicular (AC) joint sprains (Rockwood Type I or Type II).
Recommendation 103. Arthrodesis is acceptable as a salvage procedure when other procedures have failed to restore shoulder function.
Recommendation 104. Arthroplasty is acceptable when all of the following parameters are met, and the form of arthroplasty is at the surgeon's discretion:
* the presence of any of the following conditions:
* severe arthritis, or
* massive rotator cuff tears, or
* humeral head fracture or osteonecrosis, or
* humeral malunion; and
* functional impairment remains despite conservative management; and
* the condition is not amenable to less invasive treatment; and
* there is integrity of the deltoid.
Recommendation 105. Revision arthroplasty is acceptable, provided that a second shoulder orthopedist agrees, in cases of hardware failure, chronic pain and stiffness, painful glenoid erosion, or difficulty with activities of daily living. Prior authorization is required.
Recommendation 106. Urgent surgical repair is acceptable for distal biceps tendon rupture.
Recommendation 107. Repair without delay is acceptable for proximal biceps tendon rupture or complete dislocation following shared decision making as not all patients require surgical repair (see Recommendation 99).
Recommendation 108. Tenotomy or tenodesis is acceptable for bicipital tendonitis, subluxing bicipital tendon, or biceps pulley disorder when functional deficits interfere with activities of daily living (ADLs) and/or job duties after 12 weeks of conservative care emphasizing Active Therapies as outlined in Section 7.a.i.
Recommendation 109. Nerve exploration and surgical intervention is acceptable in any of the following cases, and surgical approach is at the surgeon's discretion:
* suspicion of nerve laceration or substantial injury from trauma or surgery; or
* progressive weakness or loss of function post-injury or postoperatively; or
* when functional deficits interfere with activities of daily living (ADLs) and/or job duties after 3 months of conservative care emphasizing Active Therapies as outlined in Section 7.a.i.
Recommendation 110. Distal clavicle resection is acceptable for patients with arthritis of the acromioclavicular (AC) joint after 6 weeks of conservative care emphasizing Active Therapies as outlined in Section 7.a.i. when there is a symptomatic AC joint with reproducible pain. See Recommendation 112 for clavicular fracture and Recommendation 118 for use in rotator cuff repair.
Recommendation 111. Reduction and internal fixation is acceptable for fracture not amenable to less invasive treatment.
Recommendation 112. Distal clavicle resection is acceptable as part of the repair of a clavicular fracture.
Recommendation 113. Hardware removal for a claim-related condition is acceptable at the surgeon's discretion.
Recommendation 114. Manipulation under anesthesia and/or capsular release is acceptable for post-traumatic stiff shoulder only after 3 months of conservative care emphasizing Active Therapies as outlined in Section 7.a.i. if range of motion (ROM) is below the norm and functional deficits continue to interfere with activities of daily living (ADLs) and/or job duties.
Recommendation 115. Surgery is only acceptable for symptomatic rotator cuff tears that result in weakness, decreased range of motion (ROM), decreased function, and/or pain. Surgical approach is at the surgeon's discretion. Timing for surgery depends on the type of tear:
* Immediate repair of acute full-thickness tears that are symptomatic is acceptable.
* Repair of acute partial-thickness tears or chronic tears is acceptable only if they continue to be symptomatic after 6 weeks of conservative care emphasizing Active Therapies as outlined in Section 7.a.i.
Recommendation 116. Use of a graft augmentation or patch as part of a rotator cuff tear repair requires prior authorization.
Recommendation 117. Superior capsular reconstruction requires prior authorization.
Recommendation 118. Distal clavicle resection is not recommended as a routine addition to rotator cuff repair. It is only acceptable when there is a symptomatic acromioclavicular (AC) joint with reproducible pain.
Recommendation 119. Biceps tenotomy or tenodesis is not recommended as a routine addition to rotator cuff repair. It is only acceptable when there is evidence of a biceps tendon disorder or to augment a large rotator cuff repair or revision surgery.
Recommendation 120. Shoulder/glenohumeral stabilization surgery is acceptable in any of the following cases, and patient eligibility and surgical approach is at the surgeon's discretion:
* dislocation with significant rotator cuff tear, significant labral injury (e.g., Bankart lesion), clinically significant bony deformity or loss (e.g., Hill-Sachs lesion), or fracture not amenable to immobilization; or
* recurrent dislocations when not accompanied by generalized ligamentous laxity.
Recommendation 121. Surgery is acceptable for patients with shoulder instability who do not meet the indications in Recommendation 120 only after 12 weeks of conservative care emphasizing Active Therapies as outlined in Section 7.a.i. if functional deficits continue to interfere with activities of daily living (ADLs) and/or job duties. Early surgery is acceptable if there is a recurrent dislocation during the conservative care phase.
Recommendation 122. Thermal capsulorrhaphy is not recommended.
Recommendation 123. Subacromial decompression (including bursectomy, acromioplasty, or spur removal) is not generally recommended for subacromial impingement syndrome, rotator cuff tendinopathy, or as an adjunct to rotator cuff repair.
Recommendation 124. In the absence of other surgical shoulder pathology, surgery for symptomatic superior labrum anterior and posterior (SLAP) tears is acceptable only after at least 3 months of conservative care emphasizing Active Therapies as outlined in Section 7.a.i. when functional limitations remain and/or instability significantly affects activities of daily living (ADLs) or work duties. Surgical approach is at the surgeon's discretion.
Recommendation 125. Arthroscopic exam and superior labrum anterior and posterior (SLAP) repair is acceptable when performed in conjunction with other surgical procedures. The time frames and indications for the primary procedure, as described in this Medical Treatment Guideline (MTG), must be followed. Surgical approach is at the surgeon's discretion.
Recommendation 126. Surgery for calcific tendonitis is acceptable only after 3 months of conservative care emphasizing Active Therapies as outlined in Section 7.a.i. if functional deficits continue to interfere with activities of daily living (ADLs) and/or job duties. Surgical approach is at the surgeon's discretion.
7 CCR 1101-3-17-08-8