Title 8, CALIFORNIA CODE OF REGULATIONS, SECTION 9792.20

ET AL. APPENDIX C—POSTSURGICAL TREATMENT GUIDELINES EVIDENCE-BASED REVIEWS Title 8, California Code of Regulations, section 9792.20 et seq.
Appendix C—Postsurgical Treatment Guidelines Evidence-Based Reviews(Final Regulations – Effective July 18, 2009)Labor Code section 5307.27 requires the Administrative
Director to adopt a medical treatment utilization schedule (MTUS) that is “scientific and evidence-based, peer-reviewed, andnationally recognized.” (See, also Lab. Code, § 4604.5
(b).) Labor Code section 5307.27 further provides that the MTUS shall address, at a minimum, “the frequency, duration, intensity, and appropriateness of all treatment
procedures and modalities commonly performed in workers’ compensation cases.” Labor Code section 4604.5(d)(1) provides that for injuries occurring on and after January 1,
2004, an injured worker shall be entitled to no more than 24 chiropractic, 24 occupational therapy, and 24 physical therapy visits per industrial injury. Labor Code section 4604.5
(d)(3), as amended by Assembly Bill 1073 (Statute 2007, Chapter 621), creates an exception to the 24 visit cap by providing that the 24 visit limitation does “not apply to visits
for postsurgical physical medicineand postsurgical physical medicine services provided in compliance with a postsurgical treatment utilization schedule established by the
administrative director pursuant to Section 5307.27.”

The proposed Postsurgical Treatment Guidelines, Section 9792.24.3, et al., creates an exception tothe limit of 24 visits for physical therapy, occupational therapy and
chiropractic treatment found in Labor Code section 4604.5(d)(1), for postsurgical physical medicine treatment. The proposed guidelines are adapted from the Work Loss Data
Institute’s Official Disability Guidelines (ODG) Treatment in Workers’ Comp, with the permission of the ODG’s publisher. (See, correspondencefrom Work Loss Data
Institute, Phil Denniston, President, dated March 13, 2008.) Because theWork Loss Data Institute continuously revises its guidelines, the DWC utilized the last availableversion
while conducting its rulemaking as a basis for the DWC’s postsurgical treatment guidelines. The ODG Physical Medicine Guidelines version being adapted is dated October 23,
2008 (Work Loss Data Institute, Official Disability Guidelines, Treatment in Workers’ Comp-Excerpt from the Chapter Procedures Summaries (ODG Physical Medicine
Guidelines), versiondated October 23, 2008). Future updates will be integrated into the MTUS utilizing the formal rulemaking process. The selection of the ODG Physical
Medicine Guidelines was based not only on the fact that the ODG guidelines were determined to meet the requirements of the statute (Lab. Code, § 5307.27) by RAND in its
publication entitled, Evaluating Medical Treatment Guideline Sets for Injured Workers in California, RAND Institute for Civil Justice and RAND Health, 2005 (2005 RAND
Report; see, Table 4, p. 21; Table 4.2, p. 27), but upon a thorough review of their entire Physical Medicine Guidelines by the Division of Workers’ Compensation (DWC),
theMedical Evidence Evaluation Advisory Committee (MEEAC), and designated subject matter experts. The medical evidence evaluation advisory committee (MEEAC), as
created by California Code ofRegulations, title 8, section 9792.23(a) (8 CCR 9792.23(a)) [now proposed Section 9792.26(a)], evaluated ODG’s Physical Medicine Guidelines and
made recommendations to the Administrative Director via the Medical Director pursuant to 8 CCR 9792.23(c)(1)-(c)(3) [now proposed Section 9792.26(c)(1)-(c)(3)]. Because
the 2005 RAND Report identified the ODG Guidelines as meeting the requirements of Labor Code section 5307.27, DWC determined that it was not necessary to require the
MEEAC


Title 8, CALIFORNIA CODE OF REGULATIONS, SECTION 9792.20 ET AL. APPENDIX C—POSTSURGICAL TREATMENT GUIDELINES EVIDENCE-BASED
REVIEWS Title 8, California Code of Regulations, section 9792.20 et seq.Appendix C—Postsurgical Treatment Guidelines Evidence-Based Reviews(Final Regulations –
Effective July 18, 2009)2to review the ODG’s Physical Medicine Guidelines to determine whether the guidelines were “nationally recognized” and “scientifically and evidence-
based.” (8 CCR 9792.23(c)(1) [now proposed Section 9792.26(c)(1)].) For the same reason, DWC determined that it was not necessary to require the MEEAC to review the
ODG’s Physical Medicine Guidelines to identify areas which are not “scientifically and evidence-based.” (8 CCR 9792.23(c)(2) [now proposed Section 9792.26(c)(2)].)
However, because the postsurgical treatment guidelines are anadaptation of the ODG’s Physical Medicine Guidelines, the MEEAC reviewed the ODG’sPhysical Medicine
Guidelines and applied the requirements of 8 CCR 9792.23(c)(3) [nowproposed Section 9792.26(c)(3)]. In applying the requirements of this section, the MEEAC and designated
subject matter experts, conducted a thorough review of ODG’s Physical Medicine Guidelines. The MEEAC noted that ODG’s Physical Medicine Guidelines needed
supplementation to include additional surgeries. Evidence-based reviews (EBRs) were conducted on these surgical areas to determine the mostappropriate treatments. The EBRs
reflected insufficient evidence for or against postsurgical physical medicine in many cases. “Guidelines built on synthesis of the evidence, but go one step further to provide
formal conclusions or recommendations about appropriate and necessary care for specific types of patients.” Crossing the Quality Chasm: A New Health System for the
21stCentury/Committee on Quality of Health Care in America, Institute of Medicine, National Academy Press, Washington, D.C., Fifth Printing, June 2004, p. 151. Therefore,
the first step of developing a clinical practice guideline is to do the evidence-basedreviews. The second step involves “…reli[ance] on expert panels to arrive at specific clinical
conclusions. Judgment must be exercised in this process because the evidence base is sometimes weak or conflicting, or lacking in the specificity needed to develop
recommendationsuseful for making decisions about individual patients in particular settings (Lohr et al., 1998).”Crossing the Quality Chasm, Institute of Medicine, (2001), p.
151. Thus, the MEEAC made recommendations to develop the guidelines, and the recommendationsare included in DWC’s postsurgical treatment guidelines. The postsurgical
physical medicine treatment guidelines adapted directly from ODG are labeled “[ODG].” The postsurgicalphysical medicine treatment guidelines not adapted directly from ODG
but recommended by theDWC are labeled “[DWC].” Further, in making recommendations to the Administrative Director via the Medical Director to supplement the MTUS, the
MEEAC is responsible to evaluate the developed guidelines to insure that the guidelines conform to the framework of the MTUS. The MEEAC must further take into
consideration Labor Code 4604.5(a), which provides that the MTUS is presumed to be “correct on the issue of extent and scope of medical treatment” provided to injured
employees. Clarity in the guidance of the guidelines facilitates appropriate treatment which is presumed to
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Title 8, CALIFORNIA CODE OF REGULATIONS, SECTION 9792.20 ET AL. APPENDIX C—POSTSURGICAL TREATMENT GUIDELINES EVIDENCE-BASED
REVIEWS Title 8, California Code of Regulations, section 9792.20 et seq.Appendix C—Postsurgical Treatment Guidelines Evidence-Based Reviews(Final Regulations –
Effective July 18, 2009)3be correct pursuant to the Labor Code and avoids delayed treatment, thus encouraging promptrecovery and reduced disability. Moreover, because the
postsurgical treatment guidelines constitute an exception to the 24 physical therapy visits per industrial injury pursuant to Labor Code section 4604.5(d)(1), it was necessary for
DWC in order to implement, interpret and make specific and carry out the provisions of Labor Code section 4604.5(d)(3) to define a postsurgical physical medicine period. In
order to comply with the requirement of the statute, the MEEAC and designated subject matter experts defined the postsurgical physical medicine period for the specified
surgeries based on their recommendations. The postsurgical physical medicine period frames thetime interval that is needed for postsurgical treatment allowed for the 24-visit cap
exception toapply within that period. Upon reaching the end of the time interval, the postsurgical treatmentguidelines cease to apply, reverting back to the 24-visit cap. The
following list represents the format of the EBRs conducted: (1) Topic Heading, (2) Treatment Guideline, (3) Date of review, (4) Treatment recommendation, (5) Background
research, (6) Search criteria (7) Search terms, (8) Findings, (9) Strength of evidence, (10) MEEAC Comments (if any), (11) Evidence lists. Individual Medical Treatment
GuidelinesAnkle & Foot Anterior tibial tendon Post-surgical treatment: 8 visits over 3 months Post-Surgical physical medicine treatment period: 6 monthsDate of Review:
January 3, 2008 Search Criteria: The following search terms were used for the literature search: Search Terms: Anterior tibial tendon with surgery Anterior tibial tendon with
surgery and rehabilitation Anterior tibial tendon with surgery and therapy Findings: There were no studies on the need for postsurgical physical medicine. Strength of Evidence:
IAmputation of foot Post-surgical treatment: 48 visits over 26 weeksPost-Surgical physical medicine treatment period: 12 months
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Title 8, CALIFORNIA CODE OF REGULATIONS, SECTION 9792.20 ET AL. APPENDIX C—POSTSURGICAL TREATMENT GUIDELINES EVIDENCE-BASED
REVIEWS Title 8, California Code of Regulations, section 9792.20 et seq.Appendix C—Postsurgical Treatment Guidelines Evidence-Based Reviews(Final Regulations –
Effective July 18, 2009)4Date of Review: January 3, 2008 Search Criteria: The following search terms were used for the literature search: Search Terms: Amputation of Foot
Amputation of Foot and rehabilitation Amputation of Foot and therapy Findings: There were no studies on the need for postsurgical physical medicine Strength of Evidence:
IDislocation of the peroneal tendons Post-surgical treatment: 8 visits over 3 months Post-Surgical physical medicine treatment period: 6 monthsDate of Review: January 3, 2008
Search Criteria: The following search terms were used for the literature search: Search Terms: Dislocation peroneal tendon(s) with surgery Dislocation peroneal tendon(s) with
surgery Dislocation peroneal tendon(s) with surgery and therapy Dislocation peroneal tendons(s) with surgery and therapy Findings: There were no studies on the need for
postsurgical physical medicine. Strength of Evidence: IFracture of toe [DWC] Special Consideration: Post-surgical physical medicine is rarely needed for fracture of toe.Date of
Review: December 27, 2007 Search Criteria: The following search terms were used for the literature search: Search Terms: Fracture toe rehabilitationFracture toe therapy
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Title 8, CALIFORNIA CODE OF REGULATIONS, SECTION 9792.20 ET AL. APPENDIX C—POSTSURGICAL TREATMENT GUIDELINES EVIDENCE-BASED
REVIEWS Title 8, California Code of Regulations, section 9792.20 et seq.Appendix C—Postsurgical Treatment Guidelines Evidence-Based Reviews(Final Regulations –
Effective July 18, 2009)5Findings: There were no studies on the need for postsurgical physical medicine. Strength of Evidence: IMEEAC Comments: Special Consideration: Post-
surgical physical medicine is rarely needed for fracture of toe. Peroneal tendon repair Post-surgical treatment: 8 visits over 3 months Post-Surgical physical medicine treatment
period: 6 monthsDate of Review: January 3, 2008 Search Criteria: The following search terms were used for the literature search: Search Terms: Peroneal tendon with surgery
Peroneal tendon with surgery and rehabilitation Peroneal tendon with surgery and therapy Findings: There were no studies on the need for postsurgical physical medicine.
Strength of Evidence: IPosterior tibial tendonitis Post-surgical treatment: 8 visits over 3 months Post-Surgical physical medicine treatment period: 6 monthsDate of Review:
January 3, 2008 Search Criteria: The following search terms were used for the literature search: Search TermsPosterior tibial tendonitis with surgery Posterior tibial tendonitis
with surgery and therapy Posterior tibial tendonitis with surgery with surgery and therapy Tarsal tunnel syndrome outcome of surgery in long Findings: There were no studies on
the need for postsurgical physical medicine. Strength of Evidence: I
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Title 8, CALIFORNIA CODE OF REGULATIONS, SECTION 9792.20 ET AL. APPENDIX C—POSTSURGICAL TREATMENT GUIDELINES EVIDENCE-BASED
REVIEWS Title 8, California Code of Regulations, section 9792.20 et seq.Appendix C—Postsurgical Treatment Guidelines Evidence-Based Reviews(Final Regulations –
Effective July 18, 2009)6Posterior tibial tenosynovitis (partial or complete rupture) [DWC] Post-surgical treatment: 8 visits over 3 months Post-Surgical physical medicine
treatment period: 6 monthsDate of Review: January 3, 2008 Search Criteria: The following search terms were used for the literature search: Search Terms: Posterior tibial
tenosynoistis with surgeryPosterior tibial tenosynovitis with surgery and therapyPosterior tibial tenosynovitis with surgery and therapyTarsal tunnel syndrome outcome of
surgery in long Findings: There were no studies on the need for postsurgical physical medicine. Strength of Evidence: IBurns (No Evidence Based Reviews Conducted)
Cardiopulmonary [DWC]Coronary Stenting Post-surgical treatment: 36 visits over 18 weeks Post-Surgical physical medicine treatment period: 6 monthsDate of Review: March
17, 2008 Search Criteria: The following search terms were used for the literature search: Search Terms: Coronary Stenting Coronary Stenting and Rehabilitation Coronary stenting
and therapy Stenting and rehabilitation Stenting and therapyFindings: There were no studies on the need for postsurgical physical medicine. Strength of Evidence: I
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Title 8, CALIFORNIA CODE OF REGULATIONS, SECTION 9792.20 ET AL. APPENDIX C—POSTSURGICAL TREATMENT GUIDELINES EVIDENCE-BASED
REVIEWS Title 8, California Code of Regulations, section 9792.20 et seq.Appendix C—Postsurgical Treatment Guidelines Evidence-Based Reviews(Final Regulations –
Effective July 18, 2009)7Heart Valve repair/replacement Post-surgical treatment: 36 visits over 18 weeks Post-Surgical physical medicine treatment period: 6 monthsDate of
Review: March 17, 2008 Search Criteria: The following search terms were used for the literature search: Search Terms:Heart valve repair Heart valve repair and therapyHeart
valve repair and rehabilitation Heart valve replacement Heart valve replacement and rehabilitation Heart valve replacement and therapyFindings: There were no studies on the
need for postsurgical physical medicine. Strength of Evidence: IPercutaneous transluminal coronary angioplasty (PTCA) Post-surgical treatment: 36 visits over 18 weeks Post-
Surgical physical medicine treatment period: 6 monthsDate of Review: March 17, 2008 Search Criteria: The following search terms were used for the literature search: Search
Terms: Percutaneous transluminal coronary angioplasty and rehabilitation Percutaneous transluminal coronary angioplasty and therapyPercutaneous transluminal coronary
angioplasty and physical therapy Findings: There were no studies on the need for postsurgical physical medicine. Strength of Evidence: ICarpal Tunnel Syndrome(No Evidence
Based Reviews Conducted)
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Title 8, CALIFORNIA CODE OF REGULATIONS, SECTION 9792.20 ET AL. APPENDIX C—POSTSURGICAL TREATMENT GUIDELINES EVIDENCE-BASED
REVIEWS Title 8, California Code of Regulations, section 9792.20 et seq.Appendix C—Postsurgical Treatment Guidelines Evidence-Based Reviews(Final Regulations –
Effective July 18, 2009)8Elbow & Upper ArmAmputation of arm, above the elbowPost-surgical treatment: without complications, no prosthesis: 18 visits over 4 months Post-
Surgical physical medicine treatment period: 6 monthsPost-surgical treatment: without complications, with prosthesis: 30 visits over 6 months Post-Surgical physical medicine
treatment period: 9 monthsPost-surgical treatment: with complications, no prosthesis: 30 visits over 5 months Post-Surgical physical medicine treatment period: 7 monthsPost-
surgical treatment: with complications and prosthesis: 40 visits over 8 months Post-Surgical physical medicine treatment period: 12 monthsDate of Review: January 3, 2008
Search Criteria: The following search terms were used for the literature search: Search Terms: Amputation of arm above elbow Amputation of arm above elbow and rehabilitation
Amputation of arm above elbow and therapy Findings: There were no studies on the need for postsurgical physical medicine. Strength of Evidence: ICubital tunnel release Post-
surgical treatment: 20 visits over 3 monthsPost-Surgical physical medicine treatment period: 6 monthsDate of Review: January 3, 2008 Search Criteria: The following search
terms were used for the literature search: Search Terms: Cubital tunnel releaseCubital tunnel release and rehabilitation Cabital tunnel release and therapyFindings: There were no
studies on the need for postsurgical physical medicine. Strength of Evidence: IECRB/ ECRL debridement Post-surgical treatment: 10 visits over 4 monthsPost-Surgical physical
medicine treatment period: 6 months
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Title 8, CALIFORNIA CODE OF REGULATIONS, SECTION 9792.20 ET AL. APPENDIX C—POSTSURGICAL TREATMENT GUIDELINES EVIDENCE-BASED
REVIEWS Title 8, California Code of Regulations, section 9792.20 et seq.Appendix C—Postsurgical Treatment Guidelines Evidence-Based Reviews(Final Regulations –
Effective July 18, 2009)9Date of Review: January 3, 2008 Search Criteria: The following search terms were used for the literature search: Search Terms: Extensor carpi radialis
brevis Extensor carpi radialis brevis and rehabilitation Extensor carpi radialis brevis debridementExtensor carpi radialis brevis debridement and rehabilitation Extensor carpi radialis
brevis tenotomy Extensor carpi radialis longus Extensor carpi radialis longus and rehabilitation Extensor carpi radialis longus repair Extensor carpi radialis brevis tenotomy and
therapy Extensor carpi radialis brevis debridement and therapy Findings: There were no studies on the need for postsurgical physical medicine. Strength of Evidence: IECRB/
ECCRL tenotomy Post-surgical treatment: 10 visits over 4 monthsPost-Surgical physical medicine treatment period: 6 monthsDate of Review: January 3, 2008 Search Criteria:
The following search terms were used for the literature search: Search Terms: Extensor carpi radialis brevis Extensor carpi radialis brevis and rehabilitation Extensor carpi radialis
brevis debridementExtensor carpi radialis brevis debridement and rehabilitation Extensor carpi radialis brevis tenotomy Extensor carpi radialis longus Extensor carpi radialis longus
and rehabilitation Extensor carpi radialis longus repair Extensor carpi radialis brevis tenotomy and therapy Extensor carpi radialis brevis debridement and therapy Findings: There
were no studies on the need for postsurgical physical medicine. Strength of Evidence: I
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Title 8, CALIFORNIA CODE OF REGULATIONS, SECTION 9792.20 ET AL. APPENDIX C—POSTSURGICAL TREATMENT GUIDELINES EVIDENCE-BASED
REVIEWS Title 8, California Code of Regulations, section 9792.20 et seq.Appendix C—Postsurgical Treatment Guidelines Evidence-Based Reviews(Final Regulations –
Effective July 18, 2009)10Elbow diagnostic arthroscopy and arthroscopic debridement Post-surgical treatment: 20 visits over 2 monthsPost-Surgical physical medicine treatment
period: 4 monthsDate of Review: January 3, 2008 Search Criteria: The following search terms were used for the literature search: Search Terms: Elbow arthroscopic debridement
Elbow arthroscopic debridement and rehabilitation Elbow diagnostic arthroscopy Elbow diagnostic arthroscopy and arthroscopic debridement Elbow diagnostic arthroscopy and
arthroscopic debridement Elbow diagnostic arthroscopy and rehabilitation Findings: There were no studies on the need for postsurgical physical medicine. Strength of Evidence:
IElbow collateral ligament repair Post-surgical treatment: 14 visits over 6 monthsPost-Surgical physical medicine treatment period: 8 monthsDate of Review: January 3, 2008
Search Criteria: The following search terms were used for the literature search: Search Terms: Elbow collateral ligament and rehabilitationElbow collateral ligament and
repairElbow collateral ligament repair and rehabilitationFindings: There were no studies on the need for postsurgical physical medicine. Strength of Evidence: IMuscle or tendon
transfers for elbow flexion Post-surgical treatment: 30 visits over 5 monthsPost-Surgical physical medicine treatment period: 8 monthsDate of Review: January 3, 2008
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Title 8, CALIFORNIA CODE OF REGULATIONS, SECTION 9792.20 ET AL. APPENDIX C—POSTSURGICAL TREATMENT GUIDELINES EVIDENCE-BASED
REVIEWS Title 8, California Code of Regulations, section 9792.20 et seq.Appendix C—Postsurgical Treatment Guidelines Evidence-Based Reviews(Final Regulations –
Effective July 18, 2009)11Search Criteria: The following search terms were used for the literature search: Search Terms: Muscle or tendon transfers for elbow flexion Muscle
transfers for elbow flexion and rehabilitationMuscle or tendon transfers for elbow flexion and rehabilitation Tendon transfers for elbow flexion Muscle transfers for elbow flexion
Tendon transfers for elbow flexion and rehabilitation Findings: There were no studies on the need for postsurgical physical medicine. Strength of E
Title 8, CALIFORNIA CODE OF REGULATIONS, SECTION 9792.20