Washington State Department of Labor & Industries Provider Bulletin

• 08-01-09 Provider Bulletin (09-06) Proximal Median Nerve Entrapment (PMNE) Medical Treatment Guideline
• 08-01-09 Provider Bulletin 09-05 Acute Cauda Equina Syndrome (CES) Medical Treatment Guideline
• Provider Bulletin (09-04) Coverage Decision: Spinal Cord Stimulators
• 03-20-09 Provider Bulletin (09-03): Artificial Lumbar and Cervical Disc Replacement
• 06-15-08 Provider Bulletin (08-01): Discography for Chronic Low Back Pain and Lumbar Degenerative Disc Disease
• 08-01-07 Brevio® Nerve Conduction Testing System
• 11-01-06 Provider Bulletin PB 06-06 Utilization Review Program

Forms

• Surgical Review Request Form
• Group A Provider Outpatient Procedure Notification Form
• Provider Check List Request Form

Check Lists - For use by non-Group A Providers

(The following check lists include the Provider Check List Request Form.)

Knee Procedures

• Internal Derangement  (Diagnostic Arthroscopy, ACL Repair, Meniscectomy or Meniscus Repair, Chondroplasty)
• Osteochondral Autograft  (Mosaicplasty or OATS procedure)
• Lateral Retinacular Release, Patellar Tendon Realignment or Marquet Procedure
• Subchondral Drilling or Microfracture
• Provider Bulletin PB 03-16 Review Criteria for Knee Surgery

Shoulder Procedures

• Tenodesis of Long Head of Biceps, Reinsertion of Ruptured Biceps Tendon
• Capsulorraphy or Bankart
• Partial Claviculectomy or Mumford Procedure, Treatment of AC Joint Dislocation
• Decompression of Subacromial Space/Acromioplasty and/or Distal Claviculectomy for Chronic Rotator Cuff Tendonitis
• Debridement or Repair of SLAP lesion, Repair of GLAD lesion
• Rotator Cuff Repair (Full or Partial Thickness Tear)

Other Procedures

• Carpal Tunnel Release
• Ulnar Nerve Decompression