TITLE 85
EXEMPT
LEGISLATIVE RULE
WORKERS’
COMPENSATION COMMISSION
SERIES 20
MEDICAL
MANAGEMENT OF CLAIMS, GUIDELINES FOR IMPAIRMENT EVALUATIONS, EVIDENCE, AND
RATINGS, AND RANGES OF PERMANENT PARTIAL DISABILITY AWARDS
§85-20-1. General.
1.1. Scope. --
W. Va. Code §23-4-3b(b) requires the Workers’ Compensation Board of
Managers to promulgate a rule
establishing the process for the medical management of claims and awards of
disability which includes, but is not limited to, reasonable and standardized
guidelines and parameters for appropriate treatment, expected period of time to
reach maximum medical improvement and range of permanent partial disability
awards for common injuries and diseases or, in the alternative, which incorporates
by reference the medical and disability management guidelines, plan or program
being utilized by the commission, insurance commissioner, self-insured employer
or private carrier, whichever is applicable, for the medical and disability
management of claims, with the requirements, standards, parameters and
limitations of such guidelines, plan or program having the same force and
effect as the rule promulgated in compliance herewith. This Rule satisfies this statutory
requirement. See also, W. Va. Code
§§23-1-1(b); 23-1-1a(j)(2), (3), (9), and 13); 23-1-1a(j)(13); 23-1-1b(g)(25);
23-1-13; 23-4-1(c), (d), (f), and (i); 23-4-1g; 23-4-3; 23-4-1d;23-4-3c;
23-4-6; 23-4-7; 23-4-7a; 23-4-8; 23-4-8b; 23-4-8c; and 23-4-16.
1.2. Authority. --
Pursuant to W. Va. Code,
§23-1-1a(j)(3), rules adopted by the Workers Compensation Board of Managers are
not subject to legislative approval as would otherwise be required under W. Va.
Code, §29A-3-1 et seq. Public notice
requirements of that chapter and article, however, must be followed.
1.3. Filing Date. --
December 20, 2005.
1.4. Effective
Date. -- January 20, 2006.
1.5. Repeal of former
rules. -- This exempt legislative rule repeals and replaces the following:
1) 85 C.S.R. 13, “ Protocols and Procedures for Performing Medical Evaluations
in Noise-Induced Hearing Loss Claims,” filed in the Secretary of State’s Office
January 24, 1996 and made effective February 22, 1996; 2) 85 C.S.R. 16,
“Guidelines for Permanent Impairment Evaluations, Evidence, and Ratings,” filed
in the Secretary of State’s Office January 24, 1996 and effective February 26,
1996; 3) 85 C.S.R. 20, “Guidelines for the Treatment of Workers’ Compensation
Injuries” filed in the Secretary of State’s Office August 23, 1995 and effective
October 1, 1995; 4) 85 C.S.R. 21, “Guidelines for Controlled Substances,” filed
in the Secretary of State’s Office August 23, 1995 and made effective September
22, 1995; and 5) 85 C.S.R. 1, “Administration of the Workers’ Compensation
Fund,” Sections 11, 14, and 20.
In accordance with the amendments to this rule, this exempt
legislative rule repeals and replaces 85 CSR 22, “Guidelines for Psychiatric
Permanent Impairment, Evaluations, Evidence and Ratings of Psychiatric
Impairment Due to Workers’ Compensation Injuries.”
1.6. Effective Date of
Original Filing. -- June 14, 2004.
§85-20-2. Purpose of Rule.
2.1. The purpose of
this rule is to implement the provisions of W. Va. Code §23-4-3b(b) and the
other provisions of the Code that are identified in Section 1.1 above.
2.2. Upon termination of the Commission, regulatory enforcement
of this exempt legislative rule shall transfer to the insurance commissioner to
be administered in a manner otherwise consistent with chapter twenty-three of
the West Virginia Code. W.Va. Code
§23-2C-22.
§85-20-3. Definitions.
As used in these rules, the following terms have the stated
meanings unless the context of a specific use clearly indicates another meaning
is intended.
3.1. "Code of West
Virginia" and "West Virginia Code" means the West Virginia Code
of 1931 as amended.
3.2. "Executive
Director" means the Executive Director of the West Virginia Workers'
Compensation Commission as provided pursuant to the provisions of W. Va. Code
§23-1-1b.
3.3. "Commission"
means the West Virginia Workers’ Compensation Commission as provided for by W.
Va. Code §23-1-1, et seq.
3.4. "Health Care
Vendor" or "Health Care Provider" refers to health care
providers, including providers of rehabilitation services within the meaning of
W. Va. Code §23-4-9, both in- and out-of-state who have signed provider
agreements with the West Virginia Workers' Compensation Commission, insurance
commissioner, self-insured employer or private carrier, whichever is
applicable, to provide health care for injuries or illnesses covered by Chapter
23 of the Code. For this Rule, the
terms shall mean any person, firm, corporation, partnership, association,
agency, institution, or other legal entity providing any kind of services or
equipment. The terms include, but are not limited to, hospitals, medical
doctors, dentists, chiropractors, vocational rehabilitation counselors,
vocational rehabilitation service providers, qualified rehabilitation
professional, osteopathic physicians, pharmacists, podiatrists, physical
therapists, occupational therapists, massage therapists, psychologists,
naturopathic physicians, and durable medical equipment suppliers.
3.5. "Office of
Judges" refers to the Office of Judges, as set forth in W. Va. Code
§23-5-8.
3.6. "This
rule" means the present exempt legislative rule that is designated in the
caption here as title 85, series 20.
3.7. The following will
be referred to throughout the rule by the abbreviation indicated.
a. Magnetic
resonance imaging - MRI
b. Encephalogram
- EEG
c. Computer
Assisted Tomogram - CT scan
d.
Electromyelogram – EMG
3.8. “Guides Fourth”
means the “Guides to the Evaluation of Permanent Impairment,” (4th
ed. 1993), as published by the American Medical Association.
3.9. “Maximum medical
improvement” means a condition that has become static or stabilized during a
period of time sufficient to allow optimal recovery, and one that is unlikely
to change in spite of further medical or surgical therapy.
3.10. “Permanent
impairment” means a permanent alteration of an individual’s health status and
is assessed by medical means and is a medical issue. An impairment is a
deviation from normal in a body part or organ system and its functioning. An injured worker’s degree of permanent
whole body medical impairment is to be determined in keeping with the
determination of whole person permanent impairment as set forth in the
applicable Guides. For the purposes of this Rule, the Guides’ use of the term
“whole person” impairment is the equivalent of the term “whole body”
impairment.
3.11. Chart Notes: This
type of documentation may also be referred to as "office" or
"progress" notes or “narrative report.” Providers must maintain charts and records in order to support and
justify the services provided. "Chart" means a compendium of medical
records on an individual patient. "Record" means dated reports
supporting bills submitted to the department or self-insurer for medical
services provided in an office, nursing facility, hospital, outpatient,
emergency room, or other place of service. Records of service shall be entered
in a chronological order by the practitioner who rendered the service. For
reimbursement purposes, such records shall be legible, and shall include, but
are not limited to:
a. Date(s) of
service;
b. Patient's name
and date of birth;
c. Claim number;
d. Name and title
of the person performing the service;
e. Chief
complaint or reason for each visit;
f. Pertinent
medical history;
g. Review of
medication
h. Pertinent
findings on examination;
i. Medications
and/or equipment/supplies prescribed or provided;
j. Description of
treatment (when applicable);
k.
Recommendations for additional treatments, procedures, or consultations;
l. X rays, tests,
and results; and
m. Plan of
treatment/care/outcome.
3.12. “Injured worker”
means an individual seeking to received benefits available under Chapter 23 of
the Code and/or has received and/or is receiving benefits under Chapter 23 of
the Code.
3.13. “Insurance
Commissioner” means the insurance commissioner of West Virginia as provided in
section one, article two, chapter thirty-three of the West Virginia Code, or
designated third-party administrator of the Insurance Commissioner.
3.14. “Private Carrier” means any insurer, including the
successor to the Commission, authorized
by the insurance commissioner to provide workers’ compensation insurance
pursuant to chapters twenty-three and thirty-three of the West Virginia Code,
but shall not include self-insured employers.
3.15. “Self-insurer” and “self-insured employer” mean employers
who are eligible and have been granted self-insured status under the provisions
of W. Va. Code §23-2-9.
§85-20-4. Adoption of Standards
and Acceptance of Rules.
4.1. The treatment
guidelines, standards, protocols, and limitations thereon provided for the
injuries and diseases listed in this section are designed to assist health care
providers in the evaluation and treatment of injured workers. The provisions of this Rule are not intended
to strictly dictate results and it is recognized that there may be
extraordinary cases that require treatments in addition to the treatments set
forth in this Rule. However the
treatments and limitations on treatments set forth in this Rule are presumed to
be medically reasonable and treatments in excess of those set forth in this
rule are presumed to be medically unreasonable. A preponderance of evidence, including but not limited to,
detailed and documented medical findings, peer reviewed medical studies, and
the elimination of causes not directly related to a compensable injury or
disease, must be presented to establish that treatments in excess of those
provided for in this Rule are medically reasonable. To receive reimbursement from the Commission, insurance
commissioner, self-insured employer or private carrier, whichever is
applicable, for treatment in excess of that provided for in this Rule, all
providers must thoroughly document and explain the action taken and the basis
for the deviation from this Rule and shall receive authorization before
providing said treatment.
4.2. Except as provided
for in section 5.11 of this Rule, providing treatment to an injured worker,
filling prescriptions for an injured worker, and/or acceptance of payment for
treatment, devices, or medications provided to an injured worker constitutes
acceptance by the medical provider of the Commission’s or Insurance
Commissioner’s rules and fee schedules.
4.3. Failure of the
medical provider to timely submit appropriately completed forms, failure to
comply with this Rule or any fee schedule or billing guideline, as may be from
time to time amended, and any attempt to seek reimbursement in excess of the
levels provided for in this Rule may be considered as an abusive practice for
purposes of W. Va. Code §23-4-3c and may be considered as evidence of conduct
in violation of W. Va. Code §61-3-24g. All medical reports and fee bills must be
signed by the medical vendor rendering the services or his authorized
representative. If the report or bill
is not submitted electronically, the medical vendor’s name must be legibly
printed or typed beneath the signature.
§85-20-5. Qualified Providers
and Registration.
5.1. To receive payment
as a health care provider, a provider must be enrolled as an active vendor with
the Commission. Providers may be reimbursed only for services actually provided
or supervised and for which the vendor is duly licensed. To enroll, the provider must submit the
applicable application to the Commission, completed in its entirety, along with
all documentation requested by the Commission, including, but not limited to,
all professional licenses, board certificates, business licenses, accreditation
certificates, and/or operating permits held by the provider in this or any
other state.
a. Upon
termination of the Commission, no registration is required of health care
providers. Health care professionals
are required to verify and provide proof of their licensing and certification,
including, but not limited to, all professional licenses, board certificates,
business licenses, accreditation certificates, and/or operating permits held by
the provider in this or any other state, to the Insurance Commissioner,
self-insured employer or private carrier, whomever services are provided under
this rule. In turn the Insurance
Commissioner, self-insured employer or private carrier, is required to maintain
this proof that the health care provider is qualified to provide services under
this rule.
b. Providers must
advise the Commission, the Insurance Commissioner, self-insured employer or
private carrier, whichever is applicable, if their license to practice medicine
has ever been suspended or terminated by the appropriate authority in West
Virginia or any other state and whether the provider has been convicted of any
crime in relation to his or her practice, or any felony. Providers with address or telephone number changes
must advise the Commission, the Insurance Commissioner, self-insured employer
or private carrier, whichever is applicable, in writing (by mail or facsimile),
providing both old and new information and their tax identification number on
letterhead.
5.2. Any provider who
has had his or her license to practice medicine suspended or terminated by the
appropriate authority in West Virginia or any other state, any provider who has
been convicted of any crime in relation to his or her practice, or any felony,
and/or any provider who has been suspended or terminated by the Commission or
Insurance Commissioner, whichever is applicable, pursuant to W. Va. Code
§23-4-3c, or any other provision, may be excluded by the Commission or
Insurance Commissioner, whichever is applicable, in any managed care plan
created by the Commission, the Insurance Commissioner, self-insured employer or
private carrier, whichever are applicable,.
5.3. Providers must
submit their usual and customary charges for commonly billed codes when
applying for enrollment. If the
provider is ultimately enrolled, the provider shall only be permitted to charge
the provider’s usual and customary charges, and not the maximum amount allowed
under the Commission’s, Insurance Commissioner’s, private carrier’s or
self-insured employer’s, whichever is applicable, fee schedule.
5.4. Licensed
practitioners are eligible to treat injured workers to the extent of the
practitioner’s license certification.
Providers not independently licensed must practice under direct
supervision of a licensed health care professional whose scope of practice and
specialty training includes service provided by the paraprofessional.
5.5. Reimbursement for
care will only be authorized if the provider has provided documentation of
credentialing consistent with the type of care provided.
5.6. Until the
termination of the Commission, a new Application is required to be filed with
the Commission if a provider’s name or tax identification number changes. The Application must have the original
signature of an authorized person and may be faxed initially to the
Commission’s Provider Registration unit.
Activation is not official until a complete signed application has been
received and a confirmation letter is sent at that time. The hard-copy original must be sent to:
Workers’ Compensation
Commission
ATTN: Provider Registration
P.O. Box 4228
Charleston, WV
25364-4228
a. Upon
termination of the Commission, the provider is required to keep current
provider information on file with the Insurance Commissioner, self-insured
employer or private carrier, whomever services are provided under this rule.
5.7. The provision of
health care services to injured workers under the workers’ compensation system
of this state constitutes an agreement to:
a. Accept the
Commission’s, or Insurance Commissioner’s fee schedule, as amended from time to
time by the Commission or Insurance Commissioner;
1. In
instances when the commission, and effective upon termination of the
commission, private carriers, self-insured employers or other payors, have
entered into preferred provider or managed care agreements which provides for
fees and other payments which deviate from the schedule of maximum
disbursements set forth in accordance with the provisions of W. Va. Code §23-4-3(a),
such acceptable level of payments may be set forth in the preferred provider or
managed care agreement(s);
b. Submit reports
and to make continuing reports in a timely manner and as otherwise required and
on forms required by the Commission, the Insurance Commissioner, self-insured
employer or private carrier, whichever are applicable, as from time to time
amended;
c. Retain medical
records, including, but not limited to, general medical records and X-Ray’s,
for ten (10) years and invoices, electronic or paper, for three years;
d. Timely and
fully participate in all physical and vocational rehabilitation efforts of the
Commission, the Insurance Commissioner, self-insured employer or private
carrier, whichever are applicable,;
e. Accept all
provisions of this Rule, and all policies, procedures, and other requirements
adopted from time to time by the Commission or Insurance Commissioner,
whichever is applicable; and
f. To remain
updated and familiar with all medical billing instructions, and other rules,
regulations, and procedures of the Commission, the Insurance Commissioner,
self-insured employer or private carrier, whichever are applicable,.
5.8. Health Care
Providers. Certain procedures performed
by health care providers are reimbursable by the Commission, the Insurance
Commissioner, self-insured employer or private carrier, whichever are
applicable, only when providers have certification in accordance with W. Va.
Code §30-16-20. Health care providers
must provide evidence of certification if they wish to perform videofluroscopy,
diagnostic ultrasound, electromyography, nerve conduction velocity studies,
somatosensory testing, neuromuscular junction testing, and any other diagnostic
testing identified by the Commission, the Insurance Commissioner, self-insured
employer or private carrier, whichever is applicable,.
5.9. Independent
Medical Examiners. Registered providers
may apply to be recognized by the Commission as independent medical examiners,
who provide independent examinations and recommend impairment ratings of
injured workers. A separate
application, Independent Medical Examiner Application, must be submitted and
approved by the Commission. Approval
shall only be granted if the applicant is board certified under a certification
granted by the American Board of Medical Specialties (ABMS) or the Bureau of
Osteopathic Specialists certifying boards of the American Osteopathic
Association (AOA), where such board exists.
The Commission, Insurance Commissioner, private carrier or self-insured
employer, whichever is applicable, reserves the right, in its sole discretion,
to direct the examinee to the examiner of its choosing. All independent medical examiners shall
comply with all Commission policies and procedures as a pre-requisite to
payment.
a. Upon
termination of the Commission, no registration is required of independent
medical examiners. Independent medical
examiners are required to verify and provide proof of their ABMS or AOA
certification to the Insurance Commissioner, self-insured employer or private
carrier, or to their third party administrator or managed care provider,
whomever services are provided under this rule. In turn, the Insurance Commissioner, self-insured employer or
private carrier, or their third party administrator or managed care provider,
is required to maintain this proof of certification of the independent medical
examiner.
5.10. Out-of-State
Providers. If an injured worker elects
or is directed to receive health care services from an out-of-state provider,
and that provider does not accept the Commission’s insurance commissioner’s,
private carrier’s or self-insured employer’s, whichever is applicable, fee as
payment in full, then the injured worker may be liable for the difference between
the payment and the amount charged by the out-of-state health care provider.
5.11. Given the above,
it is essential that all physicians be aware of the injured worker’s potential
liability when selecting a referral, consulting, surgical, or other provider
located in another state. Accordingly,
all referrals should be to providers registered with the Commission or within
the network of physicians authorized to provide health care services to its
injured workers by the Insurance Commissioner, private carrier or self-insured
employer, whichever is applicable, and referrals to non-registered providers
requires pre-authorization from the Commission, Insurance Commissioner, private
carrier or self-insured employer, whichever is applicable. Unless the following exceptions apply,
referral to an out-of-state provider will put the injured worker at risk for
out-of-pocket payment for medical service.
a.
Emergencies: Where there is an
urgent need for immediate medical attention to prevent death or serious and
permanent harm, the injured worker will not be personally liable for the
difference between fee schedule and the amount charged by the out-of-state
provider. The exception no longer
applies when, after emergency admission, the injured worker attains a stable
medical condition and can be transferred to either a West Virginia health care
provider or an out-of-state health care provider who has agreed to accept the
scheduled fee as payment in full. If
the injured worker refuses to be transferred, then he or she will be personally
liable for the difference in costs between the fee schedule amount and the
amount charged by the provider for services after attaining medical stability.
b. No Nearby
Qualified Provider: If no health care
provider qualified to provide needed medical services and who has agreed to
accept the Commission’s, Insurance Commissioner’s, private carrier’s or self-insured employer’s, whichever is
applicable, fee schedule as payment in full is reasonably near to the injured
worker’s home, the injured worker may request authorization for an out-of-state
provider. If the Commission, Insurance
Commissioner, private carrier or self-insured employer, whichever is
applicable, authorizes medical services from the out-of-state provider, the injured
worker will not be personally liable for the difference between fee schedule
and the amount charged by the out-of-state provider.
§85-20-6. The Role of the
Treating Physician.
6.1. Each injured
worker selects a treating physician of record who will treat the injured worker
and be responsible for coordinating all subsequent health care. The treating physician of record may be a
medical doctor, osteopath, podiatrist, or chiropractor. Any treating physician who is limited in
number of treatments by another provision of this Rule shall, upon exhaustion
of that limit, only seek reimbursement as a treating physician for services
provided in intervals consistent with those of other treating physicians. The injured worker should not seek care from
more than one provider without contacting the Commission, Insurance
Commissioner, private carrier or self-insured employer, whichever is
applicable, requesting the designation of a different attending physician, and
having that request approved. Injured
workers whose employer’s or the employer’s private carrier’s managed care plans
have been approved by the Commission or Insurance Commissioner, whichever is
applicable, or who are covered by a managed care plan adopted by the Commission
shall chose a treating physician offered under the applicable plan.
6.2. Whenever possible,
the treating physician should use the least costly mode of treatment. This generally will require that outpatient
services be used in lieu of inpatient care and the avoidance of referring
injured workers to hospital emergency rooms for care that can be rendered in
the office. The Commission, Insurance
Commissioner, private carrier or self-insured employer, whichever is
applicable, will approve payment for initial use of emergency room facilities
and services such as routine dressings, routine tests, routine medications and
routine local anesthesia. Subsequent use of the emergency room for services
will not be approved without a statement from the physician explaining the
necessity for the services rendered.
Routine visits to the emergency room shall not be approved or reimbursed
by the Commission, Insurance Commissioner, private carrier or self-insured
employer, whichever is applicable.
6.3. Treating
physicians should request referral of an injured workers who continues to
report pain and dysfunction while showing no significant measurable or
objective signs of improvement for a Permanent Partial Disability evaluation.
Such injured workers may also be discharged or referred to a different,
appropriate specialty for evaluation and possible modification of treatment.
6.4. When the treating
physician finds the injured worker to be at maximum medical improvement, the
treating physician may provide an impairment rating pursuant to applicable
Guidelines for the injured worker. If
the rating exceeds fifteen percent (15%), the Commission, Insurance
Commissioner, private carrier or self-insured employer, whichever is
applicable, may accept or reject the rating and may order an independent
evaluation of the injured worker. The
treating physician may also report a finding of Maximum Medical Improvement
without making an impairment rating, reported on Form WC-219a, “Notice of
Maximum Medical Improvement.”
6.5. The treating
physician of record shall provide a treatment plan for the medical care being
considered in narrative form as set forth in section 3.11 of this Rule.
6.6. It is the
responsibility of the treating physician to notify the Commission, Insurance
Commissioner, private carrier or self-insured employer, whichever is
applicable, of the injured worker’s
most accurate and current condition.
The initial diagnosis reported when a claim is filed often requires
updating based on diagnostic tests and clinical objective findings. Changes, additions and revisions of the
injured worker’s condition must be reported using the applicable Commission,
Insurance Commissioner, private carrier or self-insured employer, whichever is
applicable, form. All changes related
to a diagnosis code shall submitted to the Commission, Insurance Commissioner,
private carrier or self-insured employer, whichever is applicable, and must be approved by the Commission,
Insurance Commissioner, private carrier or self-insured employer, whichever is
applicable,, unless the new diagnosis is otherwise accepted by the Commission,
Insurance Commissioner, private carrier or self-insured employer, whichever is
applicable, as being causally related to the compensable injury. Bills submitted for treatment that is clearly
unrelated to the compensable diagnosis shall be denied and may serve as
evidence of abuse under W. Va. Code §23-4-3c and/or fraud under W. Va. Code
§61-3-24g. The Commission, Insurance
Commissioner, private carrier or self-insured employer, whichever is
applicable, may, in its sole discretion, recognize and identify the change,
addition, or revision as a compensable condition.
6.7. Injured workers
must request authorization from the Commission, Insurance Commissioner, private
carrier or self-insured employer, whichever is applicable, to change the
treating physician of record in their claim.
This rule does not apply in the following cases:
a. Care
transferred after initial emergency or first aid treatment if done so within 30
days of the date of injury;
b. Care
transferred to a specialist by the original treating physician; or
c. Care where an
unforeseen emergency develops which requires special facilities and skills are
not available to the treating physician or hospital.
6.8. Any change of
treating physician that does not require authorization by the Commission,
Insurance Commissioner, private carrier or self-insured employer, whichever is
applicable, will require a detailed explanation to ensure that the change is
documented on the claim file. Failure
to do so may result in the delay of benefits and will result in the denial of
payment for medical services.
6.9. When a change of
physician is authorized, the previous treating physician must file a final
report of the injured worker’s physical status on the effective date of change.
The new treating physician of record must file an initial narrative report of
his/her findings. It is the responsibility of every provider to make reasonable
effort to ascertain whether there was a prior treating physician.
6.10. Except in cases
where a consultant, anesthetist or surgical assistant is required, or the
necessity for treatment by a specialist is clearly shown, fees not
pre-authorized by the Commission, Insurance Commissioner, private carrier or
self-insured employer, whichever is applicable, will not be approved for
treatment by more than one medical vendor for the same condition over the same
period of time.
§85-20-7. Initial Reporting of
Injury.
7.1. It is the
responsibility of the injured worker to notify the employer, Commission, and
medical provider when there is reason to believe the injury or condition is
industrial in nature. Conversely, if the medical provider discovers a condition
which he or she believes to be work related or has reason to believe an injury
is work related, he or she must so notify the injured worker. Once such a
determination is made by either the injured worker or the medical provider, the
appropriate form(s) must be immediately submitted. Failure of the medical provider to timely submit the
appropriately completed forms may be considered as an abusive practice for
purposes of W. Va. Code §23-4-3c.
Failure of the injured worker to timely submit appropriately completed
forms may be considered and given appropriate weight by the Commission,
Insurance Commissioner, private carrier or self-insured employer, whichever is
applicable, in determining compensability or any other matter.
7.2. It is the medical
provider’s responsibility to ascertain whether he or she is the first attending
practitioner. If so, the medical provider will take the following action:
a. Give emergency
treatment.
b. Immediately
complete and forward the Initial Report of Injury to the Commission, Insurance
Commissioner, private carrier or self-insured employer, whichever is
applicable, and the employer.
c. Instruct and
give assistance to the injured worker in completing his or her portion of the
report of accident. The Initial report of Injury shall include a narrative
report containing the following information so there is no delay in
adjudication of the claim or payment of compensation:
1. Complete
history of the industrial accident or exposure.
2.
Comprehensive description of physical findings and prognosis.
3. Specific
diagnosis with ICD-9-CM code(s) and narrative definition relating to the
injury.
4. Type of
treatment rendered.
5. Known
medical, emotional or social conditions which may influence recovery or cause
complications.
6.
Estimated time loss due to the injury.
d. To the extent
the information called for in (c)(1) – (c)(6) is not required on the Initial
Report of Injury in use by the Commission, Insurance Commissioner, private
carrier or self-insured employer, whichever is applicable, the medical provider
shall complete the appropriate form in its entirety and provide the additional
information in the form of a narrative report.
§85-20-8. Additional Reporting
Requirements.
8.1. Whenever requested
by the Commission, Insurance Commissioner, private carrier or self-insured
employer, whichever is applicable, and at least every ninety (90) days in
situations regarding the continuation of temporary total disability benefits,
the medical provider shall report on the condition and treatment of the injured
worker. The following information must
be included in this type of report.
a. The
condition(s) diagnosed including ICD-9-CM codes and the objective and
subjective findings.
b. Their
relationship, if any, to the industrial injury or exposure.
c. Outline of
proposed treatment program, its length, components, and expected prognosis
including an estimate of when treatment should be concluded and condition(s)
stable. An estimated return to work date should be included. The probability,
if any, of permanent partial disability resulting from industrial conditions
should be noted.
d. If the worker
has not returned to work, the attending doctor should indicate whether a
vocational assessment will be necessary to evaluate the worker's ability to
return to work and why.
e. If the worker
has not returned to work, a doctor's estimate of physical and functional
capacities should be included with the report. If further information regarding
physical and functional capacities is needed or required, a performance-based
functional capacity evaluation can be requested. Functional capacity
evaluations shall be conducted by a licensed health care provider approved by
the Commission, Insurance Commissioner, private carrier or self-insured employer,
whichever is applicable, to perform this testing.
8.2. To the extent the
information called for in Section 8.1 is not required on Attending Physician’s
Report in use by the Commission, Insurance Commissioner, private carrier or
self-insured employer, whichever is applicable, the medical provider shall
complete the Attending Physician’s Report in its entirety and provide any
additional information set forth in Rule 8.1 in the form of a narrative report.
8.3. The Commission,
Insurance Commissioner, private carrier or self-insured employer, whichever is
applicable, may request, and the medical provider shall provide all chart notes
relating to the evaluation and treatment of an injured worker.
8.4. The Commission,
Insurance Commissioner, private carrier or self-insured employer, whichever is
applicable, in its sole discretion, may require additional reporting on forms
and in intervals as it deems necessary.
Medical providers shall comply with the requests of the Commission,
Insurance Commissioner, private carrier or self-insured employer, whichever is
applicable, in this regard. Failure to make reports promptly may result in the
delay of payments of benefits to the injured worker and denial of payment to
the medical vendors for services rendered.
8.5. By application for
benefits, an injured worker irrevocably waives patient-physician
confidentiality and agrees that physicians and health care providers may
release and discuss the injured worker’s medical history and medical reports
pertaining to the compensable injury or disease to the injured worker’s
employer, employer’s representative, or representatives of the Commission,
Insurance Commissioner, private carrier or self-insured employer, whichever is
applicable, assuming such discussions are otherwise permissible under
applicable law. Such discussion
includes the injured worker’s condition, treatment, prognosis, anticipated
period of disability and dates when the injured worker will reach maximum medical
improvement or be released to return to work.
Any prior injury or disease of the injured worker which impacts the
alleged injury or treatment is covered by this agreement. The claimant’s
agreement to the release of information from physicians and health care
providers includes agreement to the release of information held by facilities
where the treatment was provided. Such
facilities include, but are not limited to hospitals, clinics, emergency care
facilities, surgical centers, outpatient care facilities, diagnostic testing
facilities and rehabilitation facilities.
8.6 In any claim where
only medical benefits are being paid, the medical provider shall provide the
report described in section 8.1 within thirty (30) days of being requested to
do so by the Commission, Insurance Commissioner, private carrier or
self-insured employer, whichever is applicable.
8.7. The Commission,
Insurance Commissioner, private carrier or self-insured employer, whichever is
applicable, shall make referrals of claimants to physicians for independent
medical examinations and evaluations as required by the West Virginia Code
within twenty (20) days of the end of the one hundred twenty (120) period of
temporary total disability, unless from the record the Commission, Insurance
Commissioner, private carrier or self-insured employer, whichever is
applicable, has a reasonable belief that the period of temporary total
disability exceeds one hundred twenty (120) days.
§85-20-9. Coverage and Billing
Provisions.
9.1. The Commission,
Insurance Commissioner, private carrier or self-insured employer, whichever is
applicable, will pay for health care services, durable medical and other goods
and other supplies and medically related items as may be reasonably
required. The Commission, Insurance
Commissioner, private carrier or self-insured employer, whichever is
applicable, will only pay for those services or items that have a direct
relationship to the work related injury or disease, as determined in the sole
discretion of the Commission, Insurance Commissioner, private carrier or
self-insured employer, whichever is applicable.
9.2. A medical coverage
decision is a general policy decision to be made in the sole discretion of the
Commission, Insurance Commissioner, private carrier or self-insured employer,
whichever is applicable, to include or exclude a specific health care service
or supply as a covered benefit. These decisions are made to insure quality of
care and prompt treatment of workers. Medical coverage decisions include, but
are not limited to, decisions on health care services and supplies rendered for
the purpose of diagnosis, treatment or prognosis, such as:
a. Ancillary
services including, but not limited to, home health care services ambulatory
services, specific rehabilitative modalities;
b. Devices;
c. Diagnostic
tests;
d. Drugs,
biologics, and other therapeutic modalities;
e. Durable
medical equipment;
f. Procedures;
g. Prognostic
tests;
h. Supplies; and
i. Inpatient
hospital stays and associated charges
9.3. The Commission,
Insurance Commissioner, private carrier or self-insured employer, whichever is
applicable, with some exceptions, will use these nationally-accepted
standardized code sets for reporting medical conditions and treatment and may
adopt successor code sets without amendment to this rule:
a. Common
Procedure Terminology (CPT-4) codes (HCPCS Level I codes), for provider
professional services
b. Alpha-numeric
codes (HCPCS Level II codes) for supplies, equipment and other medical services
c. Local Codes
(HCPCS Level III) for unique Workers’-Compensation-specific services (NOTE: Use
of these non-standardized codes is limited as much as possible)
d. International
Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) for
reporting diagnoses of work-related injuries and occupational illnesses
e. Diagnostic
related groups (DRG for in-patient hospital services)
f. Revenue codes
for outpatient hospital based services
g. National drug
codes (NDC) for pharmaceuticals
9.4. CPT-4 Codes (HCPCS
Level I).
The Commission, Insurance Commissioner, private carrier or
self-insured employer, whichever is applicable, will update its vendor bill
processing system to accept many of the new codes that are implemented nationally
on an annual basis. This coding system,
which uses a five-digit numeric code and allows for a two-digit modifier, is
used to report most professional services, including Evaluation and Management,
surgical intervention, anesthesia services related to surgery, physical
medicine and other professional services.
9.5. HCPCS Level II
National Alpha-numeric Codes.
The Commission, Insurance Commissioner, private carrier or
self-insured employer, whichever is applicable, will accept many of the codes
developed by CMS for reporting those medical services and supplies not
addressed by the CPT-4 code set. This
coding system uses a five-digit alpha-numeric code, which consist of one
alphabetic character (a letter between and including A and V), followed by four
digits. The codes all begin with a
single letter and are followed by four-digits.
HCPCS codes also use modifiers, either two digits or two letters.
9.6. HCPCS Level III
Local Codes.
The Level III codes are assigned and maintained by individual carriers. Like the HCPCS II National Codes, these
codes begin with a letter (W through Z) followed by four numeric digits. The most notable difference is that these
codes are not common to all carriers.
Since 1999, the Commission has been eliminating the use of Local Codes
wherever possible; however, there are still some local codes utilized by the
Commission for services not normally reported by Medicare carriers.
9.7. ICD-9-CM Diagnosis
Codes.
The Commission, Insurance Commissioner, private carrier or
self-insured employer, whichever is applicable, shall use the ICD-9-CM coding
system to report injured worker conditions in work-related injuries and
occupational illnesses. Standard coding
conventions shall be followed in reporting diagnosis. Payment will be denied for diagnosis judged, in the sole
discretion of the Commission, Insurance Commissioner, private carrier or
self-insured employer, whichever is applicable, to not be causally related to
the compensable injury.
9.8. Written
descriptions of procedures alone will not be accepted. Billing may be submitted on the CMS-1500
(formerly, HCFA 1500) and the CMS-1450 (formerly, UB-92), or the most current
forms utilized by the Commission, Insurance Commissioner, private carrier or
self-insured employer, whichever is applicable. Pharmacy charges should be submitted using the on-line
Point-of-Sale system, but can also be reported on the Universal Claim Form, or
the most current form utilized by the Commission, Insurance Commissioner,
private carrier or self-insured employer, whichever is applicable. Certain
non-standard services unique to the Commission, Insurance Commissioner, private
carrier or self-insured employer, whichever is applicable, require Service
Invoice, Form WC-400, or the most current form(s) utilized by the Commission,
Insurance Commissioner, private carrier or self-insured employer, whichever is
applicable.
9.9.
Pre-authorization. Written
authorization must be obtained from the Commission, Insurance Commissioner,
private carrier or self-insured employer, whichever is applicable, in advance
for the procedures and services listed below, except in emergencies or where
the condition of the patient, in the opinion of the medical vendor, is likely
to be endangered by delay. Failure to comply with this rule will result in
disapproval of the medical vendor’s bill.
The vendor shall not seek reimbursement from the injured worker if
payment is denied under this provision.
This rule does not apply in cases involving initial treatment.
9.10. The following
services require prior review and authorization before services are rendered
and reimbursement made:
a. Inpatient
hospitalizations subsequent to the Date of Injury (emergency admissions are
reviewed on a retrospective basis);
b. Transfers from
one hospital to another hospital (emergencies do not require authorization);
c. Reconstructive
and restorative surgeries;
d. All surgeries;
e. Purchase of
TENS unit above the amount of $50.00;
f.
Treatment/supplies used in excess of three (3) months for TENS units;
g. Psychiatric
treatment (does not include the initial psychiatric consultation);
h. Physical
Medicine treatment in excess of this Rule;
i. Outpatient
pain management procedures (epidural steroids, facet injections, etc.);
j. Medication not
normally used in injury treatment and medication not listed on the preferred
drug list, if applicable;
k. Medication -
Controlled Substance (in excess of this Rule);
l. Durable
Medical Equipment in excess of $500.00;
m. Brainstem
evoked audiometry;
n. Repeat
diagnostic studies (Workers’ Compensation no longer requires approval for the
initial MRI, CAT scan, Myelogram, EMG, and Nerve Conduction Studies);
o.
Standard/analog hearing aids;
p. Programmable/digital
hearing aids;
q. Replacement
hearing aids;
r. Repair of
hearing aids over the price of $250.00;
s. Hearing Aid
batteries over the allowed quantity of 50 per 6 months;
t. Telephone
amplification devices;
u. Hearing aid assistance
products (V5299);
v. Non-emergency
ambulance transportation;
w. Non-emergency
air transportation;
x. All vision
services and items associated with vision;
y. All physical
and vocational rehabilitative services;
z. Retraining expenses;
aa. All oxygen
equipment, supplies, and related services;
bb. All nursing,
nursing home, and personal care services;
cc. Home or
vehicle modifications;
dd. Work
hardening;
ee. Work
conditioning; and
ff. Dental
procedures.
9.11.
Prior-authorization requests shall be made in writing or electronically
to the Commission, Insurance Commissioner, private carrier or self-insured
employer, whichever is applicable, for approval.
9.12. Medical services
not specified above do not require prior approval but will be reviewed
retrospectively to determine medical necessity. Services provided on an emergency basis are also subject to
retrospective review to validate that the service was truly an emergency, and
to determine medical necessity and relationship to the compensable injury.
9.13.
Disposable/Non-reusable Supplies.
The Commission, Insurance Commissioner, private carrier or
self-insured employer, whichever is applicable, will reimburse for supplies
prescribed by the authorized physician for use by the injured worker in the
home setting which are reasonably required, as determined in the sole
discretion of the Commission, Insurance Commissioner, private carrier or
self-insured employer, whichever is applicable. Supplies include dressings, colostomy supplies, catheters, and
other similar items. The injured
worker’s related diagnosis must be stated on the prescription form.
9.14. Durable Medical
Equipment Exceptions.
The following durable medical equipment require prior-authorization,
although reimbursed at less than $500:
a. E0585
Nebulizer with compressor;
b. E0607 Home
blood glucose monitor;
c. E0610
Pacemaker monitor;
d. E0730 TENS,
name brand;
e. E0731 Garment
for TENS/ neuro-muscular;
f. E0745
Neuromuscular stimulator, electronic shock unit; and
g. E0935 Passive
motion exercise device.
9.15. The Commission,
Insurance Commissioner, private carrier or self-insured employer, whichever is
applicable, shall deny bills for services rendered in violation of these Rules.
Injured workers may not be billed for services denied pursuant to this
provision.
9.16. Bills must be
itemized on department or self-insurer forms or other forms which have been
approved by the Commission, Insurance Commissioner, private carrier or
self-insured employer, whichever is applicable. Bills may also be transmitted
electronically using Commission, Insurance Commissioner, private carrier or
self-insured employer, whichever is applicable, file format specifications.
Providers using any of the electronic transfer options must follow Commission,
Insurance Commissioner, private carrier or self-insured employer, whichever is
applicable, instructions for electronic billing.
9.17. Bills must
specify the date and type of service, the appropriate procedure code, the
condition treated, and the charges for each service.
9.18. Bills submitted
to the Commission, Insurance Commissioner, private carrier or self-insured
employer, whichever is applicable, must be completed to include the following:
a. Injured
worker's name and address;
b. Injured
worker's claim number;
c. Date of
injury;
d. Referring
doctor's name;
e. Area of body treated, including ICD-9-CM code(s), identification
of right or left, as appropriate;
f. Dates of
service;
g. Place of
service;
h. Type of
service;
i. Appropriate
code to report services provided (including CPT, DRG, NCD, revenue codes,
etc.);
j. Description of
service;
k. Charge;
l. Units of
service;
m. Tooth
number(s);
n. Total bill
charge;
o. The name and
address of the practitioner rendering the services and the provider account
number assigned by the Commission, Insurance Commissioner, private carrier or
self-insured employer, whichever is applicable;
p. Date of
billing;
q. Submission of
supporting documentation required by the Commission, Insurance Commissioner,
private carrier or self-insured employer, whichever is applicable.
9.19. Responsibility
for the completeness and accuracy of the description of goods and/or services
and charges billed rests with the provider rendering the good or service,
regardless of who actually completes the bill form.
9.20. Bills must be
received within six (6) months of the date of service to be considered for
payment. Injured workers cannot be
billed for any invoice denied under this provision.
9.21. The following
supporting documentation is required to have been received by the Commission,
Insurance Commissioner, private carrier or self-insured employer, whichever is
applicable, before reimbursement for a service is made:
a. Laboratory and
pathology reports;
b. X-ray
findings;
c. Operative
reports;
d. Office notes;
e. Consultation
reports;
f. Special
diagnostic study reports; and
g. Special or
closing exam reports.
9.22. Requirements for
payment of fees.
Fees for examination or
treatment are approved only when made by the health care provider duly licensed
to make such examination or to render such treatment, and then only when the
medical vendor actually sees and examines the patient and actually renders or
directly supervises such treatment.
9.23. Additional
services and accommodations not reasonably required for treatment of the
compensable injury but requested by the injured worker shall be the
responsibility of the injured worker.
9.24. Failure on the
part of the health care provider or other person, firm or corporation to submit
fee bills to the Commission, Insurance Commissioner, private carrier or
self-insured employer, whichever is applicable, for services rendered within
the statutory period prohibits collection thereof from the injured employee,
the employer, private carrier, self-insured employer, Insurance Commissioner or
the Commission, whichever is applicable.
9.25. Payment for drugs
or medicine. The Commission, Insurance Commissioner, private carrier or
self-insured employer, whichever is applicable, may approve payment for drugs
or medicines furnished to the injured worker as part of routine treatment
rendered by the medical vendor. If unusual treatment is necessary, or if drugs
or medicines are to be used by the injured worker at his home in the absence of
the medical vendor, payment for a reasonable quantity of such drugs or medicines
may be approved. Application for such payment must be accompanied by a
statement of the medical vendor setting forth the necessity and purpose of the
use of such drugs or medicines.
9.26. Use of
appropriate codes to report services is required and up coding (reporting a
higher level of service than can be substantiated or actually was performed) is
prohibited. Reimbursement shall not be
made for such billing and up coding may be considered evidence of abuse under
W. Va. Code §23-4-3c and evidence of fraud under W. Va. Code §61-3-24g.
9.27. Prosthetics and
Orthotics. Upon receipt of the
attending medical vendor’s report, the Commission, Insurance Commissioner,
private carrier or self-insured employer, whichever is applicable, may refer
the injured worker to a medical vendor or a Rehabilitation Center for
evaluation to determine the type of prosthesis most beneficial for the
particular injured worker involved and whether the injured worker is in need of
training in use of the prosthesis. Upon receipt of the medical recommendations,
the Commission, Insurance Commissioner, private carrier or self-insured
employer, whichever is applicable, shall authorize the fitting of the
recommended prosthesis. Payment shall not be approved until the prosthesis is determined
to be serviceable and satisfactory. The requirement for prior approval for
prosthesis shall not apply when the attending medical vendor utilizes the
procedure of immediate amputation prosthetic application.
9.28. A durable medical
equipment supplier is required to exercise due diligence to verify that
equipment is in use, that supplies are needed, and that a valid request for
supplies has been made. Due diligence
requires, but is not limited to, a personal contact with the injured
worker. Reimbursement shall be denied
for failure to exercise this required due diligence and may be evidence of
fraud or abuse under Chapters 23 and 61 of the West Virginia Code.
§85-20-10. Supplies.
HCPCS code A4550 (Surgical Trays) is a status B code and is not
reimbursable for office procedures.
Codes with a status B are bundled services for which no separate payment
may be made. Supply costs are included in the global fee allowance for surgical
procedures performed in an office setting.
Code 99070 continues to be a non-covered, bundled code.
§85-20-11. Vision Care.
Ophthalmologists and optometrists may use CPT codes for
reporting procedures and professional services. Reimbursement for vision care equipment such as spectacles,
contact lenses, etc., should be requested using appropriate HCPCS Level II
codes. Repair or replacement of vision care equipment damaged in an accident
will not be approved for payment unless the injured worker suffers a
compensable physical injury in the accident.
§85-20-12. Psychiatric compensability, treatment and impairment ratings. (Effective Date: January 20, 2006.)
12.1. Purpose. The purpose of this section is to develop
guidelines for the determination of compensability, treatment, evaluation and
permanent impairment rating of claimants for psychiatric disabilities arising
from injuries sustained in the course of and resulting from employment. This rule is applicable to evidence
submitted by any party to a claim and to evidence gathered by the commission,
Insurance Commissioner, private carrier or self-insured employer, whichever is
applicable.
12.2. Definitions. As used in these rules, the following terms
have the stated meanings unless the context of a specific use clearly indicates
another meaning is intended.
a. “Work
injury-related psychiatric disorders” means those psychiatric disorders caused
by or aggravated by a work injury or disease.
Attached as Exhibit A is a list of psychiatric diagnoses which are, by
definition, not significantly contributed to by a work-related injury, unless
the disorder ends in the phrase “due to a general medical condition” where the
general medical condition is caused by the work-related injury. In order to be regarded as work-related, symptoms
of an injury-related psychiatric diagnosis must be manifest within 6 months of
the injury or significant injury-related complication based on credible medical
evidence.
b. “Causation
legal standard” means a physical, chemical, or biologic factor contributed to
the occurrence of a medically identifiable condition. A medical determination is required to confirm the feasibility of
the contributing factor could result in the occurrence of the condition (AMA
Guides 4th Ed., Glossary).
c. “Aggravation,
legal standard” means a physical, chemical,
biological or medical condition significantly contributing to the
worsening of a condition in such a way that the degree of permanent impairment
increased by more than 3%. (AMA Guides 4th Ed., Glossary). For the impact to merit allocation of permanent
impairment, the ultimate increase of impairment at MMI must at least be 3%.
d.
“Apportionment” means a distribution or allocation of causation among
multiple factors that caused or significantly contributed to the injury or
disease and existing impairment.
e. “Psychiatric
impairment” means the loss of, loss of use of, or derangement of mental,
emotional or brain functioning.
f. “Permanent
psychiatric impairment” means impairment that has reached maximum medical
improvement which is static or well stabilized with or without psychiatric
treatment or that is not likely to remit despite psychiatric treatment of the
impairing condition.
g. “Permanent
partial psychiatric impairment” means impairment that is assigned a percentage
of impairment rating from the W. Va. Workers’ Compensation Impairment
Guidelines for Psychiatric Impairment (Exhibit B).
h. “Temporary total psychiatric impairment” means a
psychiatric condition that in and of itself, or in combination with a physical
condition, makes the claimant unable to function in the work setting, but for
which the claimant has not reached maximum medical improvement.
i. “Maximum medical improvement, psychiatric (stabilized
psychiatric condition)” means a condition or state that is well-stabilized and
unlikely to change substantially in the next year, with or without medical
treatment. Over time, there may be some
change; however, further recovery or deterioration is not anticipated. Evaluators should recognize that many
psychiatric disorders improve to a state of maximum medical improvement within
nine months of the onset of reasonable management.
12.3. Evidentiary
Requirements.
The evidentiary weight to be given to a report will be
influenced by how well it demonstrates that the evaluation was conducted in
accordance with the rule and three attached Exhibits (Exhibit A, Exhibit B, and
Exhibit C). Exhibit A lists disorders and conditions not significantly
contributed to by a work-related injury. Exhibit B is a guideline for providing
impairment ratings. Exhibit C is a report outline for psychiatric independent
medical evaluations. The evaluator must address and memorialize each bold face
section found in Exhibit C.
12.4. Compensability.
Services may be approved to treat psychiatric problems only if they are a
direct result of a compensable injury.
As a prerequisite to coverage, the treating physician of record must
send the injured worker for a consultation with a psychiatrist who shall examine
the injured worker to determine 1) if a psychiatric problem exists; 2) whether
the problem is directly related to the compensable condition; and 3) if so, the
specific facts, circumstances, and other authorities relied upon to determine
the causal relationship. The
psychiatrist shall provide this information, and all other information required
in section 8.1 of this Rule in his or her report. Failure to provide this information shall result in the denial of
the additional psychiatric diagnosis.
Based on that report, the Commission, Insurance Commissioner, private
carrier or self-insured employer, whichever is applicable, will make a
determination, in its sole discretion, whether the psychiatric condition is a
consequence that flows directly from the compensable injury.
a. A Diagnosis
Update Form WC-214 must be attached to the treating physician’s report in order
to request the psychiatric condition be added as an approved diagnosis.
12.5. Treatment
guidelines. Treatment of mental
conditions to injured workers is to be goal directed, time limited, intensive,
and limited to conditions caused or aggravated by the industrial condition.
Psychiatric services to workers are limited to those provided by psychiatrists
and licensed psychologists, and according to department policy.
a. Initial
evaluation, and subsequent treatment must be authorized by Commission,
Insurance Commissioner, private carrier or self-insured employer, whichever is
applicable, staff. The report of
initial evaluation, including test results, and treatment plan are to be sent
to the injured worker's attending provider, as well as the Commission,
Insurance Commissioner, private carrier or self-insured employer, whichever is
applicable. A copy of sixty-day narrative reports to the Commission, Insurance
Commissioner, private carrier or self-insured employer, whichever is
applicable, is also to be sent to the attending provider. In addition, the following are required:
Testing results with scores, scales, and profiles; report of raw data
sufficient to allow reassessment by a panel or independent medical examiner.
Use of the current Diagnostic and Statistical Manual of the American
Psychiatric Association axis format in the initial evaluation and sixty-day
narrative reports, and explanation of the numerical scales are required.
b. Understanding
that psychiatric conditions may arise as a consequence of injury, it is
recognized that these conditions need to be treated. It is expected that with resolution of the injury, there will be
resolution of the psychiatric injury.
The Commission, Insurance Commissioner, private carrier or self-insured
employer, whichever is applicable, is not responsible for the on-going
management of chronic or pre-existing psychiatric conditions which it does not
view as directly related to the injury.
12.6. In circumstances
when a psychiatric condition does not causally relate to the injury of an
injured worker, the Commission, Insurance Commissioner, private carrier or
self-insured employer, whichever is applicable, may authorize treatment solely
in its discretion for a limited period of time to maximize the opportunity for
recovery from the work related injury.
In such cases, no psychiatric diagnosis need be added to the list of
compensable conditions in order to obtain the treatment.
12.7. Psychological
Evaluation Guidelines.
a. General
principles. Professional standards for
psychological examiners. Psychologists
providing services for the commission, Insurance Commissioner, private carrier
or self-insured employer, whichever is applicable shall adhere to all relevant
standards for practice as set forth by the American Psychological Association
(Ethical Principles, Standards for Providers of Psychological Services, and
Specialty Guidelines).
b. Purpose.
The purpose of the psychological assessment is to obtain a current view
of the claimant’s emotional and cognitive functioning, interpersonal
relationships and approach to tasks.
Symptoms and behaviors must be sampled through interview techniques,
checklists, and standardized psychological measurements. Long term personality traits and
dysfunctions should be identified.
Inferences should be made regarding motivation and dissimulation
(faking). It is assumed that
psychological assessments are comprehensive and not limited to the presentation
of psychometric data. Even when part of
an interdisciplinary team, the psychologist has responsibility for recommending
additional evaluations and interventions by other health care professionals as
deemed necessary.
c. Initial Evaluation. Clinical judgment should be used to delete
inappropriate or unnecessary testing and add additional appropriate objective
measures to adequately assess the intellectual, emotional, personality and
functional status of the claimant.
1. Intelligence
Assessment. During the initial
evaluation a standardized intelligence test should be administered. Acceptable tests include the most recently
standardized/normed versions of either the Wechsler Adult Intelligence Scale
(WAIS) or the Stanford-Binet. An
intelligence screening measure is not an acceptable alternative to completion
of a full battery exam. Behavioral
observations of an individual in a structured testing environment are an
important component of the testing process and therefore such clinical
observations should be provided. All
subtest scores as well as the Verbal.
Performance and Full-Scale IQ scores should be reported. If the claimant is completing a repeat IME,
there should be a compelling reason present (e.g., head injury, brain disease,
substance abuse and self-reported cognitive changes) to justify
re-administration of an IQ test.
2.
Achievement testing – Achievement testing, such as the Wide Range
Achievement Test-Revised or the Peabody Individual Achievement Test, should be
administered during the initial evaluation.
Such tests are used to demonstrate that the claimant has the requisite
reading skills to understand and reliably respond to objective measures of
personality. They are also used to help
determine whether the claimant might have a diagnosis of Learning Disability
for rehabilitation purposes.
3.
Personality assessment – The type of personality instrument(s) to be
used depends on the claimant’s intellectual capabilities and reading or
listening comprehensive abilities. If
indicated based on interview, claimant history or previous testing that the
examiner has reason to suspect the claimant cannot adequately comprehend the
item content of the personality measure, the examiner will need to screen for
reading comprehension using standardized measures such as the WIAT-reading
comprehensive subtest or the Woodcock-Johnson (Revised) passage comprehensive
subtest. IF the claimant does not have
adequate reading comprehension abilities, the examiner will need to objectively
assess listening comprehension abilities (e.g., WIAT Listening Comprehension
Subtest) prior to administration of a taped version of any personality
measure. Taped versions of personality
tests are acceptable for claimants with visual acuity problems but should not
be given if listening comprehension is below acceptable levels for the selected
personality measure. Reading/listening
comprehension measures completed should provide a grade-equivalent reading/listening
level that can be compared to reading requirements of the personality measure
selected.
The personality measure selected should be normed
on a psychiatric sample and not reflect “personality traits” of a normal
population. At a minimum, personality
assessment should include tests that address not only acute and chronic
symptoms of emotional disorders but also long-standing personality
characteristics. Personality assessment
should utilize instruments with empirical/objective based scoring systems and
appropriate norms. A summary of
subscale scores when available should be included (e.g., MMPI-II profile sheet
or a Welsh Code) in the report.
Ideally, a measure of dissimulation should be incorporated into the
specific test administered to address the validity of results (e.g., MMPI-II,
Personality Assessment Inventory).
4. Supplementary testing. If indicated, additional
measures can be administered. These
measures should demonstrate adequate psychometric norms and may address:
A. Neuropsychological screen. Screening for
the presence or absence of organic dysfunction in a claimant should address
attention and concentration, memory, judgment, language skills and
visual/spatial abilities.
B. Dissimulation
C. Somatization
D. Mood disorders/suicide probability
E. Anxiety/Stress disorders
5. Comprehensive neuropsychological evaluations.
When indicated by the neuropsychological screen or claimant’s history, a
comprehensive neuropsychological evaluation consisting of accepted evaluation
procedures should be completed by a psychologist qualified and trained in
neuropsychology. A psychologist
qualified to interpret neuropsychological evaluations should document extensive
training at the graduate or post-doctoral level in a program specifically
designed for neuropsychological training or complete intensive training in
administration and interpretation by a qualified neuropsychologist.
6. Integration of findings. A detailed report
integrating all the data from observations, test responses and their interpretation,
results of previous assessments and any other relevant data such as school
records, rehabilitation reports, and medical findings should be prepared. Address any inconsistencies noted between
behavioral observations and tests responses or previous assessments.
12.8. Psychiatric
Independent Medical Evaluation (IME) Guidelines.
a. Professional
standards for examiners. Examiners for the Commission, Insurance Commissioner,
private carrier or self-insured employer, whichever is applicable, are expected
to adhere to professional standards of competent practice established by the
State Licensing Boards, National Certifying Organizations and Professional
Associations, and to Codes of professional, ethical, and legal conduct
promulgated by these organizations.
They must also follow the West Virginia Workers’ Compensation Guidelines
for Psychiatric Impairment (Exhibit B) and
applicable West Virginia law. Clinical
assessment procedures and measures utilized in forming an expert opinion must
be generally accepted in the expert’s scientific community. In forming his expert opinion, the examiner
must use the standard of “Reasonable Medical Probability”, meaning that the
presence of the disorder, and the causation of the disorder by a work injury or
disease is “more likely than not.”
b. General
principles. A psychiatric examiner should be an objective evaluator who has no
conflict of interest and no prejudgement regarding the claimant’s condition or
the presence or absence of impairment.
The examiner should not be the treating psychiatrist or vice versa.
c. Psychological
evaluations and testing must be a part of every initial IME of a claimant to
provide a comprehensive view of his mental, intellectual, and personality
functioning. A psychological test
report may be submitted as a separate document from the psychiatric IME.
d. Reports shall
be prepared in a manner consistent with the Psychiatric IME Report Outline,
attached hereto as ‘Exhibit C’ and incorporated herein by reference.
1.
Identifying data. Provide identifying data as outlined in the attached
guideline.
2.
Consent. Explain to the
claimant the nature and purpose of the examination.
3. Chief
complaint. Ascertain the claimant’s
primary complaint.
4. History
of present illness. Chronological
background and development of the symptoms or behavioral changes culminating in
the present state.
A. Using the attached guideline, provide a
detailed chronological accounting of the circumstances surrounding the injury
and the development of the symptoms or behavioral changes culminating in the
present state.
5. Personal
and social history
A.
Obtain a detailed personal and social history from the claimant using
the attached guideline.
6. Review
of systems
A. Provide a review of the claimant’s general
organ and neurological systems.
7. Past
medical history
A.
Using the attached guideline, provide a complete accounting of the
claimant’s past medical history.
8. Family
medical and psychiatric history
A.
Using the attached guideline, provide a complete accounting of the
claimant’s family medical and psychiatric history.
9. Mental
status exam
10. Summary
of other sources of information
A.
Using the attached guideline, provide a complete accounting of pertinent
psychiatric information obtained from other sources.
11.
Diagnosis
A. List all psychiatric diagnoses and
conditions according to the latest edition of Diagnostic and Statistical Manual
of Mental Disorders published by the American Psychiatric Association.
12.
Opinions
A. For each psychiatric diagnosis, provide
information on each of the five areas listed in the attached guideline. The basis of all opinions must be explicit
and the report should contain the evidence upon which the conclusions and
opinions were based. All reasoning
processes should be outlined to explain exactly how the particular conclusion
was reached. Opinions must be stated in
terms of “reasonable medical certainty” or “reasonable medical probability.”
13.
Recommendations
A. Using the attached guideline, provide
recommendations for further examinations, consultations, re-examinations,
psychiatric treatment and rehabilitation.
§85-20-13. Coverage Medication
Checks.
Medication checks may be billed if needed, but should be
reported using the appropriate Evaluation and Management or Drug Management
procedure codes. Medication checks for psychiatric medication require the use
of an ICD-9-CM code to identify the compensable mental health condition.
§85-20-14.
Medication/Injections.
Professional services for administering injections to an
injured worker in an office setting for the treatment of a compensable injury
may be reimbursable. Effective January 1, 2003, the cost of medication
administered through other-than-oral method may be billed as a separate line
item using appropriate HCPCS II “J” codes.
Legend drugs dispensed by physicians will not be reimbursed except in
emergency situations.
§85-20-15. Dental Services.
15.1. Standard dental
treatment necessary as a result of a compensable injury to the face or head is
covered under the Workers’ Compensation program. Repair or replacement of dentures and other dental appliances
damaged in an accident will not be approved for payment unless the injured
worker suffers a compensable physical injury in the accident. Except in cases of emergency, prior
authorization must be obtained for any and all dental services provided.
15.2. The Commission,
Insurance Commissioner, private carrier or self-insured employer, whichever is
applicable, will not approve payment for treatment of a preexisting dental
deficiency or disease, unless it is clearly established that such preexisting
condition is prohibiting treatment of or recovery from an industrial injury. In
such cases the Commission, Insurance Commissioner, private carrier or
self-insured employer, whichever is applicable, must be provided with a
complete report of the preexisting condition and authorization granted prior to
rendering treatment.
§85-20-16. Experimental
Procedures.
16.1. Services
investigative or experimental in nature or unsafe and not accepted by the
general medical community are not reimbursable by the Commission, Insurance
Commissioner, private carrier or self-insured employer, whichever is
applicable.
16.2. To be considered
for reimbursement by the Commission, Insurance Commissioner, private carrier or
self-insured employer, whichever is applicable, medical devices must have gone
through FDA pre-market notification submission or pre-market approval
application or be exempt for commercial distribution on the national level.
Pre-market approval designation is preferred because this designation requires
sufficient information to reasonably assure the safety and effectiveness of the
device.
§85-20-17. Unusual treatment.
17.1. In cases
requiring unusual treatment not contemplated under ordinary circumstances, the
medical vendor must inform the Commission, Insurance Commissioner, private
carrier or self-insured employer, whichever is applicable, immediately of the
condition or complications present. If the necessity for additional treatment
and its causal relationship with the compensable injury is clearly indicated,
authorization for such treatment may be granted by the Commission, Insurance
Commissioner, private carrier or self-insured employer, whichever is
applicable, if it otherwise is deemed to be medically reasonable and additional
professional fees may be paid at a rate commensurate with the services rendered
in addition to the fee specified by the Commission, Insurance Commissioner,
private carrier or self-insured employer, whichever is applicable.
17.2. New or
experimental therapies always require prior authorization from the Commission,
Insurance Commissioner, private carrier or self-insured employer, whichever is
applicable. The Commission, Insurance
Commissioner, private carrier or self-insured employer, whichever is
applicable, will require a detailed, credible and otherwise sufficient
explanation of the anticipated outcomes of the proposed therapy. The Commission, Insurance Commissioner,
private carrier or self-insured employer, whichever is applicable, may
authorize a trial of the therapy, for a duration identified by the Commission,
Insurance Commissioner, private carrier or self-insured employer, whichever is
applicable, prior to acceptance of any modality. Approval of new or experimental therapies is within the sole
discretion of the Commission, Insurance Commissioner, private carrier or
self-insured employer, whichever is applicable.
§85-20-18. Organ Transplants.
18.1. Transplants are not generally accepted or
reimbursed by the Commission, Insurance Commissioner, private carrier or
self-insured employer, whichever is applicable; however, requests are reviewed
on a case-by-case basis. All
transplants must be pre-approved by the Commission, Insurance Commissioner,
private carrier or self-insured employer, whichever is applicable, prior to issuance of authorization.
18.2. Transplants which
are needed, in whole or in part, because of an intervening cause, such as long
term alcohol consumption, smoking, or other tobacco use shall be declined
coverage by the Commission, Insurance Commissioner, private carrier or self-insured
employer, whichever is applicable.
§85-20-19. Other Non-Covered
Services.
19.1. Diagnostic
Studies. No payment is allowed for:
a.
Plethysmography;
b. Temperature
gradient studies;
c. Fomentation;
d.
Thermography;
e. Routine lab
studies in back injury claims; or
f. Routine X-rays
which the Commission, Insurance Commissioner, private carrier or self-insured
employer, whichever is applicable, determines, in its sole discretion, are
medically unreasonable or medically unsupported as defined under 85 C.S.R. 28.
19.2. Payment to
Complete Reports. No payment is allowed
for routine status reports, Attending Physician’s Report WC-219 Form, other
routine reports requested by the Commission, Insurance Commissioner, private
carrier or self-insured employer, whichever is applicable, relating to care
that has already been provided, or for completion of the medical portion of the
report of injury. Providers shall not
charge injured workers or any others for completion of the WC-219 form.
19.3.
Miscellaneous. No payment will
be made for the following services:
a. Telephone
calls;
b. Telephone
consultations by providers;
c. Writing or
phoning prescriptions;
d. Education
materials;
e. Babysitting;
f. Lost or stolen
items;
g. Vitamins;
h. Diet pills;
i. Dietary
supplements;
j. Weight loss
programs;
k. Physical
fitness programs;
l. Acupuncture;
m. Swimming
therapy/aquatic therapy (unless under direct supervision of a physical
therapist);
n. Homeopathy;
o. Massage
therapy, except that up to 3 sessions of massage therapy will be allowed if
massage therapy is not the sole means of treatment;
p. Copying or
supplying needed records;
q. Costs
associated with office audits; and
r. Saunas.
§85-20-20. Payment for
appearance at hearings.
A party causing the cancellation of an examination of a medical
doctor, osteopath, or chiropractor may be charged a $100 cancellation fee by
said provider if forty-eight (48) hours notice of said cancellation is not
provided.
§85-20-21. Treatment of
unrelated conditions.
The Commission, Insurance Commissioner, private carrier or
self-insured employer, whichever is applicable, may pay for treatment of a
condition which was not caused by the injury only if the Commission, Insurance
Commissioner, private carrier or self-insured employer, whichever is
applicable, determines, in its sole discretion, that the unrelated condition is
preventing recovery by aggravating the occupational injury. Any unrelated condition must be reported to
the Commission, Insurance Commissioner, private carrier or self-insured
employer, whichever is applicable, before payment is considered. Pre-existing conditions which prevent
recovery but do not aggravate the compensable injury shall not be covered.
§85-20-22. Consultations.
22.1. The treating physician may refer an injured
worker for a first-time consultation without prior authorization when the need can be clearly
documented and has been reported to the Commission, Insurance Commissioner,
private carrier or self-insured employer, whichever is applicable. The first-time consultation to a specialist
does not require prior authorization; however, should additional consultations
in the same specialty field be performed, Commission, Insurance Commissioner,
private carrier or self-insured employer, whichever is applicable, approval is
required.
22.2. The consultant
must submit a written report to the Commission, Insurance Commissioner, private
carrier or self-insured employer, whichever is applicable, after the exam has
been carried out. The report shall
contain the information required in Rule 8.2 and 8.1 above. Invoices from providers, other than the
attending physician, should specify the name of the referring physician. In billing those services, the appropriate
consultation procedure code from the Evaluation and Management section of the
AMA CPT coding system shall be utilized.
22.3. If a specialist
will be providing continuing care, the Commission, Insurance Commissioner,
private carrier or self-insured employer, whichever is applicable, must be
notified so that an approval for a transfer or concurrent care may be
considered.
22.4. The Commission,
Insurance Commissioner, private carrier or self-insured employer, whichever is
applicable, reserves the right to arrange a consultation prior to authorizing
any services, equipment, or supplies.
Requests for treatment will be approved or denied upon review of the
entire medical record.
22.5. Consultation
Versus Referral. A consultation is
considered to include those services rendered by a specialist whose review and
opinion of the evaluation and/or treatment of an injured worker’s condition is
requested by another provider, or an official party in the claim, such as the
injured worker’s attorney, the employer, the Commission, Insurance
Commissioner, private carrier or self-insured employer, whichever is
applicable, etc. The consulting
provider must submit a written report that becomes part of the Commission’s,
Insurance Commissioner’s, private carrier’s or self-insured employer’s,
whichever is applicable, claim record on the injured worker. When the
consulting provider assumes the continuing care of the injured worker, any
subsequent services rendered by this provider are no longer considered a
consultation.
22.6. A referral is
considered to be the transfer of the total or specific care of a patient from
one provider to another. If this
involves a change of treating physician, an authorization is required from the
Commission, Insurance Commissioner, private carrier or self-insured employer,
whichever is applicable. A referral for
specialty services, such as surgery, requires approval by the Commission,
Insurance Commissioner, private carrier or self-insured employer, whichever is
applicable.
§85-20-23. Miscellaneous
Coverage and Reimbursement Issues.
23.1. Hernia. The Commission, Insurance Commissioner,
private carrier or self-insured employer, whichever is applicable, shall not
approve payment for conservative treatment of an otherwise compensable hernia condition, except for the initial
examination for diagnostic purposes, and except where it is shown that the
employee has some chronic disease or is otherwise in such physical condition
that it is considered unsafe for him to undergo such operation. Payment for
surgical repair of a hernia cannot be considered until all required forms have
been filed and the claim determined compensable.
23.2. Amputation
reports. In cases involving
amputations, the physician must mark the exact line of amputation on the
prescribed form (Amputation Chart). To avoid error, the exact point of
amputation must also be described in the written report and the Amputation
Chart and report must be carefully checked to be certain that they agree.
IV. SPECIFIC TREATMENT
GUIDELINES
The following are treatment guidelines for specific
conditions. However, the usage of the
term “guidelines” should not be interpreted to suggest that the guidelines are
to be given any less legal weight than an exempt legislative rule is otherwise
given. The provisions of Section 4 of
this Rule apply in their entirety to these guidelines.
§85-20-24. Treatment
Guidelines: Post Concussion Syndrome.
24.1. Post concussion
syndrome is a clinical syndrome characterized by a variety of vague symptoms
including a headache, dizziness, memory dysfunction and depression, following
head trauma. There is little relationship between the serious nature of the
trauma and the severity and duration of the symptoms.
24.2. The diagnostic
criteria consists of a persistent dysfunctional state following head trauma
without clinical or laboratory sign of serious intracranial or cervical spine
disorder.
24.3. The appropriate
diagnostic tests and evaluations are as follows:
a. Neurological
examination;
b. MRI;
c. EEG;
d.
Electronystagmyogram; and
e.
Neuropsychological testing if no improvement after four weeks.
24.4. Symptomatic
therapy for post concussion syndrome includes:
a. Analgesia;
b. Medication for
labyrinthine dysfunction;
c. The use of
narcotic medications is not indicated; and
d. Severe
dizziness or mental/emotional problems may require hospitalization for acute
care rehabilitation.
24.5. While the
estimated duration of care is variable, a return to work is anticipated in four
weeks or less.
24.6. The anticipated
outcome is full recovery. In some cases there may be residual symptomatology
such as dizziness or mental/emotional changes. These conditions may be
disabling and may be permanent.
§85-20-25. Treatment
Guidelines: Corneal Abrasion.
25.1. Corneal abrasion
is usually caused by a foreign body striking the eye resulting in a disruption
of the corneal epithelium. The foreign body does not remain in the eye.
25.2. The diagnostic
criteria consists of complaints of pain and blurred vision. Photophobia may or
may not be present.
25.3. Appropriate
diagnostic tests and evaluations include a determination of visual acuity, a
slit lamp examination and, when indicated, a dilated fundus examination.
25.4. Treatment is
administered on an outpatient basis and consists of topical antibiotics,
cycloplegics, and a pressure patch. For severe pain analgesics may be
indicated.
25.5. The duration of
care consists of daily visits up to 72 hours with a return to work within two
days unless there are complications.
25.6. The anticipated
outcome is full recovery.
§85-20-26. Treatment
Guidelines: Corneal Foreign Body.
26.1. Corneal foreign
body generally occurs when striking stone; hot metal may perforate the cornea
and enter the eye. Contaminated foreign bodies pose a risk for corneal ulcers
or systemic toxicological effect.
26.2. The diagnostic
criteria consists of pain which occurs either immediately after the injury or
within the first twenty-four hours, accompanied by a sensation of something in
the eye, and photophobia. The pain is aggravated by blinking or moving the eye.
Vision may be affected if the foreign body is in the visual axis.
26.3. The appropriate
diagnostic tests and examinations consist of a comprehensive examination,
including determination of visual acuity, a slit lamp examination and dilated
fundus examination when indicated to rule out intraocular foreign bodies. An
orbital x-ray or CT scan may be indicated if there is a suspicion of ocular or
orbital penetration.
26.4. Treatment is
administered on an outpatient basis and consists of the following:
a. Removal of
embedded foreign body;
b. Topical
antibiotics, cycloplegics, and pressure patch;
c. Analgesics for
the first several days;
d. Daily visits
until the cornea is healed; and
e. If a scar
remains in the visual axis, corrective lenses or surgery may be required to attain
optimal vision.
26.5. In uncomplicated
cases the injured worker is expected to return to full work within one to two
days.
26.6. Full recovery is
expected unless the foreign body leaves a significant scar in the visual axis,
in which case decreased visual acuity may be permanent.
§85-20-27. Treatment
Guidelines: Hyphema.
27.1. Hyphema is
bleeding within the anterior chamber of the eye, typically caused by a severe
blunt trauma to the eye rupturing intraocular blood vessels. Hyphema may be associated
with disruptions of the trabecular meshwork and lead to angle recession
glaucoma. Early complications include elevated intraocular pressure causing
blood staining of the cornea, vision loss, and most significantly, rebleeding
which will occur in up to 30% of the cases within the third to fifth day.
Rebleeding may cause marked elevation of intraocular pressure, corneal blood
staining and visual loss. Late complications may include angle - recession
glaucoma and cataract. Injured workers at considerable risk for complications
include those with sickle cell or other coagulopathy.
27.2. Diagnostic
criteria consist of a history of a blunt trauma to the eyes. The physical
findings may include red blood cells visible within the anterior chamber, a layered
clot filling the entire anterior chamber and/or intraocular pressure elevation.
27.3. The appropriate
diagnostic tests and examinations are as follows:
a. Immediate
referral to an opthalmologist as this is an ocular emergency;
b. A comprehensive
examination by an ophthalmologist including a slit lamp exam, determination of
the intraocular pressure, and a dilated fundus examination if possible;
c. Orbital x-rays
may be indicated to rule out other orbital injuries; and
d. A platelet
count and coagulation study as indicated as well as a sickle prep, and
hemoglobin electrophoresis as indicated.
27.4. Appropriate
treatment is as follows:
a. Outpatient
treatment is indicated if the hyphema is not severe, there are no complications
present and the injured worker is reliable. Treatment consists of the
following:
1. Strict
bed rest for five days;
2. Daily
eye examination;
3.
Medication, which may include the following: topical cycloplegics,
steroids, ocular hypotensive and oral prednisone and/or aminocaproic acid;
4. Hard
shield to be worn day and night; and
5. A
gonioscopy after 2-3 weeks.
b. Inpatient
treatment is indicated for significant hyphema, marked intraocular pressure
elevation, complication or unreliable care and consists of the following:
1.
Medication as noted for outpatient care;
2.
Hospitalization with strict bed rest for five days; and
3. Surgical
evacuation of the clot.
27.5. Return to full
work is anticipated in three weeks for uncomplicated cases. Evidence of
disruption of intraocular structures dictates lifetime monitoring for glaucoma
and cataracts.
27.6. The anticipated
outcome is resolution of the hyphema with return of visual acuity.
§85-20-28. Treatment Guidelines:
Eyelid Laceration.
28.1. Eyelid
lacerations may occur from blunt injuries or from laceration by a sharp object.
They may involve only skin, eyelid muscles, eyelid margin, and the lacrimal
drainage system and may be associated with an orbital foreign body.
28.2. The diagnostic
criteria consists of laceration and bleeding, which may be profuse.
28.3. The appropriate
diagnostic tests and examinations consist of a comprehensive examination
including a visual acuity and a slit lamp examination to rule out an additional
injury. A dilated fundus examination may be conducted when indicated.
28.4. Appropriate
treatment is as follows:
a. Outpatient
treatment is appropriate for uncomplicated lacerations. Sutures are generally
removed in one to two weeks and medication may include antibiotics and
analgesics.
b. Inpatient
treatment is appropriate for injuries involving the lacrimal drainage system or
those penetrating the orbit. The surgical repair may or may not require general
anesthesia. Intravenous antibiotics are often indicated. Depending on the
severity of the injury and overall condition of the injured worker, a one to
two day hospital stay may be required. Medications may include topical, oral or
parenteral antibiotics and analgesics.
28.5. In uncomplicated
cases the injured worker is expected to return to full work within two weeks
with medical follow- up in four weeks. Damage to the eyelid muscles resulting
in traumatic ptosis may require six to twelve months to resolve, or may ultimately
require surgical repair.
28.6. The anticipated
outcome is full recovery.
§85-20-29. Treatment
Guidelines: Canalicular Laceration.
29.1. Laceration in the
medial eyelid may injure the upper or lower canaliculus or lacrimal sac,
resulting in constant tearing or abscess in the lacrimal sac (dacryocystitis).
The presence of an infection within the lacrimal system usually requires
surgical repair.
29.2. The appropriate
diagnostic criteria consists of a laceration in the medial eyelid. Any laceration
to the punctum may include canalicular laceration. Tearing or bloody tears and
laterally displaced punctum may be present.
29.3. The appropriate
diagnostic tests and examinations consist of a comprehensive examination,
including visual acuity, slit lamp, examination, dilated fundus examination and
probing of the canaliculus. Orbital x-rays or CT scan is appropriate if a
fracture or foreign body is suspected.
29.4. Appropriate
treatment is as follows:
a. Outpatient
treatment is appropriate for simple lacerations and repair. Treatment consists
of surgical repair including stent placement and topical drops and oral
antibiotics as indicated.
b. Inpatient
treatment is appropriate for contaminated or complicated wounds. Treatment
consists of the following:
1. Surgical
repairing; may include complex reconstruction;
2.
Antibiotics and topical medications as indicated; and
3. Lacrimal
bypass surgery if repair is unsuccessful.
29.5. The estimated
duration of care in uncomplicated cases is two weeks with follow-up in 3 - 6
months.
§85-20-30. Treatment
Guidelines: Orbital Contusion.
30.1. An orbital
contusion is usually a result of blunt trauma causing swelling and ecchymosis
of the orbit not associated with any fractures or significant lacerations.
30.2. The diagnostic
criteria consists of a history of a blunt trauma to the ocular area, with
progressive swelling of the lids, ptosis, proptosis of the eye and diplopia.
30.3. The appropriate
diagnostic tests and examinations consist of:
a. Comprehensive
examination, including an assessment of visual acuity, slit lamp examination,
and a dilated fundus examination;
b. Orbital
x-rays; and
c. CT scan may be
indicated.
30.4. The appropriate
treatment is as follows:
a. Outpatient
treatment is appropriate in injuries without complications. Treatment includes
analgesics, ice packs and systemic antibiotics as indicated.
b. Diminished
visual acuity or severe pain may indicate a more extensive injury and may warrant
inpatient treatment for further evaluation and treatment.
30.5. In uncomplicated
cases the estimated return to work is one to two days. Disability may be longer
if diplopia or ptosis persists.
30.6. The anticipated
outcome is resolution of the swelling and diplopia with return of normal ocular
motility.
§85-20-31. Treatment
Guidelines: Orbital Fracture.
31.1. Fractures of the
orbit may be indirect, resulting in a “blowout” of the orbital floor or medial
wall, or direct involving fractures of the orbital rims.
31.2. The appropriate
diagnostic criteria consists of a history of blunt trauma to the eye, usually
by an object larger then the bony orbital opening. The eye may appear proptosis
or enophthalmic. Ocular motility is usually diminished. There is usually
numbness over the cheek due to injury to the infraorbital nerve. There may be a
palpable fracture of the orbital rim. There may also be a fracture of the
zygomatic arch.
31.3. The appropriate
diagnostic tests and examinations are as follows:
a. A
comprehensive examination by an ophthalmologist is necessary, including a
visual acuity, slit lamp examination and dilated fundus examination;
b. X-ray of the
orbits; and
c. Coronal CT
scans.
31.4. Appropriate
treatment is as follows:
a. In
uncomplicated cases outpatient treatment is appropriate and consists of the
following:
1.
Outpatient follow-up for 1 - 2 weeks;
2. Oral
antibiotics; and
3.
Analgesics may be required.
b. Inpatient
treatment is appropriate for severe fractures or other complicated injuries.
Treatment consists of the following:
1. Surgical
repair;
2.
Medications include antibiotics and analgesics; and
3.
Hospitalization from 1 - 3 days.
31.5. The estimated
duration of care is as follows:
Diplopia may resolve spontaneously within one to two weeks with
small fractures not requiring repair. Double vision generally resolves within
two to three weeks after surgical repair unless there is intrinsic damage to
the extraocular muscles.
Modified work may be required with diplopia resolved. Heavy
work can generally be resumed three weeks after injury if surgery is not
required, or three weeks after surgical repair.
31.6. The anticipated
outcome is resolution of diplopia and normal functioning of the eye. Numbness
over the cheek may persist for one year or longer and is not affected by
surgical repair.
§85-20-32. Treatment
Guidelines: Corneoscleral Lacerations.
32.1. Corneoscleral
lacerations are potentially severe injuries resulting from sharp objects making
forceful contact with the globe.
32.2. The appropriate
diagnostic criteria consists of:
a. A detailed
examination by an ophthalmologist including visual acuity, slit lamp exam,
intraocular pressure and dilated fundus exam.
b. CT scan of
orbits may be required.
32.3. Appropriate
treatment is as follows:
a. Small partial
thickness lacerations:
1.
Follow-up and/or patching; and
2. Bandage
contact lens application and follow-up.
b. Full thickness
corneal lacerations:
1. Bandage
lens application;
2.
Cyanoacrylate tissue adhesive and protective shield;
3. Surgical
repair under general anesthesia and hospitalization;
4.
Cycloplegic, steroid and antibiotic drops; and
5. Hospitalization:
0 - 7 days.
32.4. The estimated
duration of care and anticipated outcome:
a. Partial
thickness laceration: The injured
worker should wear a protective shield for three to six weeks. Modified work
may be done after several days. Normal visual function should be restored after
six weeks.
b. Full thickness
simple corneal lacerations: Treatment lasts from two to four months. Protective
shield should be worn for six weeks. Return to full work after suture removal
is normally in three to four months if vision is adequate for fusion.
c. Lacerations
involving lens, uveal tissue and retina: Six months are normally required to
achieve stability after which contact lens correction of the aphakic condition
may allow good visual recovery.
§85-20-33. Treatment
Guidelines: Chemical Ocular Injuries.
33.1. Chemical injuries
may result from an almost infinite variety of agents contacting the ocular
surface, with the extent of the injury largely a function of the nature of the
substance involved, how much ocular surface is involved, and duration of
exposure.
33.2. The appropriate
diagnostic criteria is as follows: A detailed examination is performed after
copious irrigation (see treatment). It is vitally important to know the
chemical causing the injury, its concentration and amount of exposure.
In alkali burns, the Hughes classification (grading or corneal
haziness and loss of blood vessels at limbus) is helpful in assessing long term
prognosis.
33.3. The appropriate
treatment is as follows:
a. Acute phase (0
to 7 days).
1.
Immediate copious irrigation using any nontoxic irrigating solution;
2. Detailed
ophthalmologic exam, including pH level of eye secretions;
3. Topical
steroids, antibiotic drops, topical ascorbate and cycloplegic agents;
4.
Follow-up outpatient for 3 weeks;
5.
Immediate referral to ophthalmologist for alkaline burns; and
6.
Monitoring for systemic effect of toxin.
b. Severe
chemical injuries should be hospitalized for treatment for several days.
33.4. The estimated
duration of care depends on the extent of the initial injury. Milder injuries
may permit return to work after several days. Moderate chemical injuries (if
bilateral) may need several weeks to recover. Severe burns (if bilateral) may
be blinding. In many cases corneal transplants may be able to restore vision.
§85-20-34. Treatment
Guidelines: Functional Capacity Evaluations: Work Conditioning and Work
Hardening Rehabilitation Programs.
(Effective Date: February 1, 2005)
34.1. Functional
capacity evaluations. Functional
capacity evaluations measure or quantify the physical abilities of an injured
worker identified as essential in performing suitable, gainful employment
and/or objectively define an injured worker’s functional abilities or
limitations in the context of safe and productive work. A functional capacity evaluation does not
reflect what an individual should be able to do; but rather, what an individual
can do or is willing to do at a given time. The functional capacity evaluator
must be qualified by reason of training and experience and must employ valid,
generally accepted scientific methodology in determining the injured worker’s
ability.
34.2. Functional capacity evaluation providers. Functional capacity evaluations shall be
performed by an approved licensed occupational therapist or physical therapist,
with the limited exception as described within this subsection. Medical doctors, doctors of osteopathy and
chiropractors shall not perform functional capacity evaluations, unless they
meet the exception described in the section.
34.3. Functional
capacity evaluation provider qualifications.
a. The approved
functional capacity evaluation provider shall:
1. Submit
specific documented post professional education and training in occupational
rehabilitation and/or training for the model of functional capacity evaluation
they are providing, and
2. Have a
minimum of one year of supervised patient care experience in an outpatient
industrial, orthopedic or sports medicine setting. A minimum of 25% of the provider in training’s work experience
must be spent working with injured workers.
b. Limited
exception. If approved by the
commission, Insurance Commissioner, private carrier or self-insured employer,
whichever is applicable, nationally certified athletic trainers, exercise
physiologists, medical doctors, doctors of osteopathy and chiropractors may be
allowed to perform functional capacity evaluations.
1. In its
sole discretion the commission, Insurance Commissioner, private carrier or
self-insured employer, whichever is applicable, may grant this limited
exception only to those that have demonstrated to the commission, Insurance
Commissioner, private carrier or self-insured employer, whichever is
applicable, the ability to perform high quality functional capacity
evaluations. At the sole discretion of
the commission, Insurance Commissioner, private carrier or self-insured
employer, whichever is applicable, those providers who demonstrate their skill
in the performance of these services may be allowed to provide these
services. These providers will be
subject to the usual review and quality assurance programs (review of
applicants and monitor performance) as designated by the commission, Insurance
Commissioner, private carrier or self-insured employer, whichever is
applicable. Each approved provider will
successfully complete a number of test cases.
The primary goal of these guidelines is to assure only valid, high
quality exams are rendered to injured workers.
2. Exams
performed by commission, Insurance Commissioner, private carrier or
self-insured employer, whichever is applicable, approved providers under this
limited exception may be required by the Commission, Insurance Commissioner,
private carrier or self-insured employer, whichever is applicable, to be
supervised by a licensed occupational therapist or physical therapist. All functional capacity evaluations
performed by these providers may also be required by the Commission, Insurance
Commissioner, private carrier or self-insured employer, whichever is
applicable, to be signed by the person performing the exam and by the
supervising licensed occupational therapist or physical therapist.
3.
Functional capacity evaluations performed by unapproved providers shall
have no force and effect for evidentiary purposes, nor shall the commission,
Insurance Commissioner, private carrier or self-insured employer, whichever is
applicable, pay for this service.
c. The commission
may perform site inspections and all functional capacity evaluation providers
must meet the commission’s functional capacity evaluation criteria. Upon termination of the Commission, this
provision regarding site inspections shall also terminate.
d. The
commission, Insurance Commissioner, private carrier or self-insured employer,
whichever is applicable, shall require each approved provider to successfully
complete a number of test cases. An
ongoing quality assurance system will monitor the quality of functional
capacity evaluation providers after a provider is approved. The commission, Insurance Commissioner,
private carrier or self-insured employer, whichever is applicable, will
establish the quality assurance system.
34.4. Indications for
functional capacity evaluations. A
functional capacity evaluation is indicated if the medical, physical therapy,
work hardening, work conditioning records are unclear in regard to the injured
worker’s physical and functional abilities to return to suitable gainful
employment or proceed with a vocational rehabilitation plan.
34.5. Authorizations
for functional capacity evaluations. If
a treating provider determines a functional capacity evaluation is needed, the
initial functional capacity evaluation can be performed without prior
authorization, as long as it is a Level 1 examination; Provided, if the
functional capacity evaluation is to be performed by a treating provider, then
pre-authorization is required to be received from the Commission, Insurance
Commissioner, private carrier or self-insured employer, whichever is
applicable, for all functional capacity evaluations. All subsequent functional capacity evaluations performed by
non-treating providers will require prior authorization.
34.6. Purpose. The purpose of the functional capacity
evaluation is to enable the provider to:
a. Determine the
injured worker’s physical and functional status;
b. Determine if
the injured worker is able to return to the pre-injury job;
c. Determine the
injured worker’s Physical Demands Strength Rating level and other capabilities
for the physical demands of work as defined by the United States Department of
Labor. For definitions related to
functional capacity evaluations, see Appendix §85-20-F; and
d. Determine the injured worker’s material and
non-material handling abilities.
34.7. Types of
functional capacity evaluations. The
Commission, Insurance Commissioner, private carrier or self-insured employer,
whichever is applicable, will recognize and reimburse for two (2) levels of
functional capacity evaluations, a Level 1, or limited functional capacity
evaluation, and Level 2, or comprehensive functional capacity evaluation.
a. A Level 1
functional capacity evaluation will be performed prior to entry into a work
hardening or work conditioning program or as a focused physical and functional
evaluation prior to returning to pre-injury employment or objectively
identified vocational rehabilitation goals.
1. The FCE
provider generally will perform a Level 1 exam in a one (1) to, two (2) hour
timeframe.
b. A Level 2 exam
will be a comprehensive evaluation used for the quantification of an injured
worker’s physical and functional abilities to establish a vocational
rehabilitation plan or goal, permanent total disability evaluation or as a
physical and functional evaluation prior to entering a job search.
1. The
provider will generally perform a Level 2 evaluation in a three (3) to four (4)
hour timeframe.
c. Functional capacity
evaluations are to be performed using standard and generally accepted tests,
protocols and methodologies and will address issues associated with worker
participation and physical effort.
Restrictions in the ability to perform a physical action, task or
activity in an efficient, typically expected or competent manner may be
physiological, biomechanical or psychophysical in nature. Therefore, the evaluator should address
whether the performance restrictions are physiological, biomechanical or
psychophysical in nature.
d. Components of
all functional capacity evaluations include but are not limited to a review of
medical records, worker interview, physical examination and tests simulating
real functional tasks addressing capacity to fulfill the material and
non-material handling requirements of work as defined by the United States
Department of Labor.
1. Unless
otherwise specified, requested, or documented to be of limited utility because
of lack of relevance to the vocational goal or determined to be a safety hazard
to the injured worker by the evaluator, material handling testing will, at a
minimum, include: a maximum safe lift, floor to waist lifting, waist to
shoulder lifting, overhead lifting, carrying, pushing, and pulling.
2. Unless otherwise
specified, requested or documented to be of limited utility because of lack of
relevance to the vocational goal or determined to be a safety hazard to the
injured worker by the evaluator, non-material handling test will, at a minimum,
include: stair climbing, standing, walking, sitting, balancing, reaching,
stooping (bending), crouching (squatting), kneeling, crawling and handling
(grasping).
34.8. Functional
Capacity Evaluation Report. The
functional capacity evaluation report shall contain, as a minimum:
a. A summary of
the injured worker’s compensable and non-compensable injuries and/or coexistent
physical or medical impairments or diagnoses as they relate to specific job
demands of the injured worker’s pre-injury employment or identified vocational
goal;
b. The length of
the evaluation and the test components of the evaluation and the methodology
used;
c. The injured
worker’s material handling abilities, including lifting, carrying, pushing and
pulling;
d. The injured
worker’s non-material handling abilities, including standing, walking, sitting,
climbing, balancing, stooping, kneeling, crouching, crawling, reaching and
handling;
e. The injured
worker’s demonstrated Physical Demand Level and demonstrated areas of restriction
or limitations in the Physical Demand Level as outlined in the United States
Department of Labor’s Dictionary of Occupational Titles;
f. The
reliability of injured worker’s reported symptoms including consistencies and
inconsistencies between injured worker’s subjective reports, medical record
review, documented physical findings, and test results;
g. The injured
worker’s level of demonstrated physical effort/cooperation and/or presence of
nonorganic signs and symptoms and/or presence of symptom magnification syndrome
or chronic pain disorder;
h. The signature
of the person performing the test and, if appropriate in accordance with the
provisions of 34.3.b. the signature of the individual supervising the test,
with their qualifications and/or certifications that testing was performed in
accordance with these rules and the established professional standards;
i. Documentation
that the injured worker’s informed consent was obtained prior to testing; and
j. The
evaluator’s summary with conclusions and recommendations.
34.9. Work Conditioning
and Work Hardening Rehabilitation Programs. Occupational rehabilitation programs,
including work conditioning and work hardening, have the goal of assisting the
injured worker with unresolved physical, functional, behavioral, and vocational
needs following acute care. The
treatment focus of these rehabilitation programs is aimed at restoration of
work-related function. Physical and
occupational therapists provide the physical and functional components within
these programs.
a. A work
conditioning program is an intensive, work-related, goal-oriented, conditioning
program designated specifically to restore systemic neuromuscular activities,
including strength, endurance, movement, flexibility, motor control, and
cardiopulmonary functions. The
objective of the work conditioning program is to restore or maximize physical
ability and function to enable the injured worker to return to work.
b. Work hardening
programs are of two types:
1. A
general work hardening program is highly structured, goal-oriented, outcome
focused, individualized, progressive and supervised treatment program designed
to maximize physical abilities and enable the injured worker to return to work. Such a program may be offered at any time
throughout the recovery phase. The
program focuses on functional restoration and return to work. Goals of the program include, but are not
limited to, improvement of cardiopulmonary and neuromuscular functions,
including strength, endurance, movement, flexibility, stability, and motor
control functions, education, and symptom relief. A general work hardening program may follow and supplement or
enhance the goals achieved in work conditioning.
2. A
comprehensive work hardening program includes all the components of a general
program but is also multidisciplinary in nature and must meet the guidelines on
Multidisciplinary Pain Management. See
section thirty-six of this Rule (Rule 20, §85-20-36) for a description of the
services typically associated with these types of programs. All comprehensive work hardening programs
and multidisciplinary functional restoration programs require prior
authorization from the commission, Insurance Commissioner, private carrier or
self-insured employer, whichever is applicable, and are handled on a
case-by-case basis.
34.10. Work
Conditioning and Work Hardening Rehabilitation Programs: Admission Criteria.
To be eligible for these programs, the injured worker must have
a return to work goal, a job goal, have stated or demonstrated willingness to
participate, and have identified systemic neuromuscular physical and functional
deficits that interfere with work.
a. A functional
capacity evaluation is required prior to entering any work conditioning or work
hardening program unless it is determined and documented to be unnecessary by
the program director and/or treating physician.
b. A vocational
assessment that is job-focused and individualized may be required prior to
entry into a work hardening program. A
limited vocational assessment may be appropriate when the goal is a return to
the pre-injury employer. A functional
job description or job analysis may be required when modified or alternate duty
with the pre-injury employer is the goal.
A rehabilitation evaluation is required when employment with a new
employer is the goal.
34.11. Work
Conditioning and Work Hardening Rehabilitation Programs: Discharge Criteria.
The injured worker shall be discharged from the work
conditioning or work hardening program when:
a. The
anticipated goals and expected outcomes have been met;
b. It can be
documented that the injured worker is unable to continue to progress toward the
anticipated goals and expected outcomes;
c. It can be
documented that the injured worker declines to continue the program;
d. It can be
documented that the injured worker fails to comply with the requirements for
participation; or
e. The program
director determines the injured worker will no longer benefit from the work
conditioning or work hardening program.
Upon discharge from the work conditioning or work hardening program, the
program director shall notify the claimant’s employer, the commission, Insurance
Commissioner, private carrier or self-insured employer, whichever is
applicable, and/or any other referral source with the following information:
1. Reasons
for program termination;
2. Clinical
and functional status;
3.
Recommendations regarding return to work; and
4. Recommendations
for follow-up services.
f. Only the
injured worker’s treating physician, program director, or the commission,
Insurance Commissioner, private carrier or self-insured employer, whichever is
applicable, shall discharge an injured worker from a work conditioning or work
hardening program.
34.12. Referrals to
Work Conditioning and Work Hardening Programs.
Referrals to work conditioning and work hardening programs will
be accepted from the treating physician of record, the commission, Insurance
Commissioner, private carrier or self-insured employer, whichever is
applicable, or an independent medical evaluator selected by the commission,
Insurance Commissioner, private carrier or self-insured employer, whichever is
applicable.
34.13. Components of an Occupational Rehabilitation
Program. An occupational rehabilitation
program shall consist of the following components:
a. Providers of
work conditioning and work hardening shall have the following qualifications.
1. Work
conditioning and work hardening programs will be directed by a licensed
occupational therapist or physical therapist who has completed training in a
specific industry accepted work conditioning or work hardening training
model. The provider will have a minimum
of one year of supervised patient care experience in an outpatient, industrial,
orthopedic, or sports medicine setting, of which a minimum of 25% must have
been spent with work-related injury care.
2. It is
acknowledged that other providers may be able to provide highly useful
services. At the sole discretion of the
commission, Insurance Commissioner, private carrier or self-insured employer,
whichever is applicable, those treating providers who demonstrate their skill in
the performance of these services may be allowed to provide these
services. These treating providers will
be subject to the usual review and quality assurance programs (review of
applicants and monitor performance) as designated by the commission, Insurance
Commissioner, private carrier or self-insured employer, whichever is
applicable,. Each approved provider
will successfully complete a number of test cases. The primary goal of these guidelines is to assure high quality
services are rendered to injured workers.
3. A
licensed health care professional must be “on site” at all times while
treatment is being rendered to the injured workers.
4. The
supervising daily staff members of the work conditioning and work hardening
program may be composed of exercise physiologists, nationally certified
athletic trainers, licensed occupational therapists, licensed physical
therapists, licensed occupational therapy assistants and licensed physical
therapy assistants.
5. All
program directors and supervising daily staff members shall be approved by the
commission’s, Insurance Commissioner’s, private carrier’s or self-insured
employer’s, whichever is applicable,
approval process.
6. Any
change in program directorship or supervising daily staff must be communicated
to the commission, Insurance Commissioner, private carrier or self-insured
employer, whichever is applicable.
7. The
staff to injured worker ratio in both work conditioning and work hardening
programs will not exceed 1 to 8 at any time.
8. Direct
observation of program participants by a staff member is required at all times.
b. Work
conditioning and work hardening programs are a form of physical medicine
services. These programs are also
subject to the treatment services restrictions contained in the physical medicine
treatment guidelines. The commission,
Insurance Commissioner, private carrier or self-insured employer, whichever is
applicable, on a case-by-case basis may approve initiation of such programs
when their provision will exceed such guidelines.
c. Work
conditioning will be attended two (2) to four (4) hours per day. Work hardening will be attended four (4) to
eight (8) hours per day. Work
conditioning and work hardening programs will be attended five (5) days per
week. Program duration for either work
conditioning or work hardening will not exceed four (4) weeks; however, the
commission, Insurance Commissioner, private carrier or self-insured employer,
whichever is applicable, on a case-by-case basis, may approve program
extension.
d. Material
handling components of the work conditioning and work hardening programs shall
be at a minimum: 12” and floor to waist lift, waist to shoulder lift, overhead
lift, carry, push, pull, and maximum lift.
e. Non-material
handling components of the work conditioning and work hardening programs shall
typically include balancing, overhead reach, forward reach, repetitive
squatting, sustained kneeling, crawling, stair climbing, walking, standing, and
sitting. Both material handling and non-material handling goals shall be
consistent with identified functional goals of the individual injured worker.
f. The
educational component of the work conditioning/work hardening programs will
include prevention of re-injury, benefits of a home exercise program, self-treatment
of symptoms, activity control of symptoms, body mechanics, benefits of
exercise, nutrition, and healthy living habits.
g. All work
conditioning programs shall have a minimum of 1,250 square feet of dedicated
non-office clinic space. The commission,
Insurance Commissioner, private carrier or self-insured employer, whichever is
applicable, may perform site inspections and all work conditioning and work
hardening programs must meet the commission, Insurance Commissioner, private
carrier or self-insured employer, whichever is applicable, facility criteria.
34.14. Providers of
work conditioning or work hardening programs are required to provide the
following information in their reports in the timeframe as provided:
a. A brief
summary of the injured worker’s medical issues and problems as related to
specific job demands;
b. Initial and
discharge evaluations;
c. Attendance
records, including the time spent in each session;
d. Duration of
the program;
e. Material
handling abilities;
f. Non-material
handling abilities;
g. The injured
worker’s current physical demand strength rating as defined in the United
States Department of Labor, “Dictionary of Occupational Titles,” and deficits,
if any, for the physical demand level of the established vocational goal;
h. Consistency of
the injured worker’s reported symptoms, including consistencies and
inconsistencies between the injured worker’s subjective reports and physical
findings.
i. Level of
demonstrated physical effort, cooperation and/or the presence of symptom
magnification syndrome or chronic pain behavior;
j. Treatment summary with conclusions, restrictions,
limitations, and recommendations;
k. Signature of
the program director; and
l. Reports will
be bi-weekly, upon exit or discharge from the program and/or as requested by
the referral source or the commission, Insurance Commissioner, private carrier
or self-insured employer, whichever is applicable.
34.15. If an injury or
incident occurs during a work conditioning or work hardening program, a signed
and dated incident report must be filed by the treating therapist and submitted
to the the commission, Insurance Commissioner, private carrier or self-insured
employer, whichever is applicable, within three (3) working days of the
incident. The incident report shall
include as a minimum:
a. Name of the
injured worker;
b. Claim number
of the injured worker;
c. Date of
incident;
d. Description of
incident;
e. Description of
injury to the injured worker;
f. Name of
witnesses;
g. Name of
facility, and supervising daily staff member; and
h. Name of
facility director.
Following an injury or incident, unless in the case of an
emergency, the injured worker will be referred by the facility to his treating
physician for re-evaluation. The work
conditioning/work hardening program may be temporarily suspended. The injured worker’s ability to resume the
work conditioning/work hardening program will be evaluated on a case-by-case
basis and the decision to re-enter the program will be made by the program
director in conjunction with the treating physician and the commission,
Insurance Commissioner, private carrier or self-insured employer, whichever is
applicable.
§85-20-35. Treatment Guidelines:
Cervical Musculoligamentous Injury (Sprain/Strain).
35.1. Symptoms are
believed to be related to a partial stretching or tearing of the soft tissues
(muscles, fascia, ligaments, facet joint capsule, etc.). Neck pain may be
accompanied by vague upper extremity complaints. The recovery period is of
variable duration, but generally is less than three or four weeks.
35.2. The appropriate
diagnostic criteria consists of the following:
a. Pertinent
historical and physical findings documenting the mechanism and degree of force
and the time sequence before the onset of symptoms is important. The onset of
neck pain and paraspinal muscle spasm begins either suddenly after the injury
occurs or develops gradually over the next 24 hours. This pain is usually
aggravated by motion of the neck and frequently is relieved by rest. It can be
accompanied by paresthesia or a sense of weakness in the upper extremities
related to the muscle spasm in the neck. Physical findings include tenderness
to palpation, spasm of the paravertebral muscles and aggravation of the pain
with motion.
35.3. The appropriate
diagnostic tests and examinations are as follows:
a. If indicated
by examination, anteroposterior, lateral, lateral flexion and extension x-rays
of the spine and open mouth view to visualize the odontoid process are
appropriate. Other x-rays may be added to the roentgenographic series as
indicated. Straightening of the cervical spine is frequently observed on the
lateral x-ray.
b. Further
imaging may be indicated depending upon clinical course.
35.4. The appropriate
treatment is as follows:
a. Outpatient
treatment:
1.
Nonoperative treatment:
A.
Indications: Almost all injured workers with cervical musculoligamentous
(sprain/strain) can be treated conservatively. However, disruption of
intervertebral ligaments with subluxation is an indication for surgery.
B.
Treatment options:
1.
Analgesics;
2. Muscle
relaxants;
3.
Anti-inflammatory drugs, non-steroidal;
4. Physical
modalities and/or rehabilitative procedures may be helpful;
5.
Occasional trigger point injections may be helpful; and
6. Manual
manipulation and mobilization.
b. Inappropriate
treatment:
1.
Operative treatment is inappropriate for cervical strain;
2. Narcotic
medication for prolonged period of time; and
3.
Inpatient treatment.
35.5. The estimated
duration of care is 1 to 4 weeks; not to exceed 8 weeks.
35.6. A diagnosis of
sprain/strain exceeding this 8 week period requires detailed
re-evaluation. The Commission,
Insurance Commissioner, private carrier or self-insured employer, whichever is
applicable, may require an IME to verify the diagnosis and will authorize continued
treatment/coverage in its sole discretion.
35.7. The anticipated
outcome:
a. Resumption of
normal activity without residual symptoms in most cases.
35.8. Modifiers (age,
and co-morbidity). If the injured
worker has not responded to the above-outlined treatments within four weeks, the
injured worker must be referred to an appropriate specialist.
§85-20-36. Treatment
Guidelines: Acute Herniated Cervical Disc.
36.1. A cervical disc
syndrome is a condition in which there is a bulging or rupture of the
intervertebral disc. This may be lateral, compressing a root and causing a
radiculopathy, or midline, compressing the spinal cord and causing a
myelopathy. This most often occurs at the C4-5, C5-6 and the C6-7 disc levels.
When the C4-5 disc ruptures there is pressure on the C5 root. This may cause
pain over the top of the shoulder in the “epaulet” distribution. Tingling is
not common. There may be weakness of the deltoid muscle. Occasionally the
biceps reflex is diminished. When the C5-6 disc ruptures there is pressure on
the C6 root with pain as well as tingling and decreased sensation over the
thumb and index finger, weakness of elbow flexion, and diminution of the biceps
and brachial radialis reflexes. When the C6-7 disc ruptures there is pressure
on the C7 root with pain and tingling in the index and middle fingers, weakness
of elbow extension, and diminution of the triceps reflex. There can be more
extensive weakness than noted above, although the description is that of the
classic syndrome. There may be changes in other reflexes, and the sensory
abnormalities may be somewhat variable. Pain, sensory changes or weakness may
predominate because of ill-defined differences in sensibility of the different
components of the nerve. Over time the pain may resolve due to permanent damage
to pain fibers, leaving the injured worker with motor and sensory dysfunction,
which still may merit decompression.
Myelopathic symptoms may occur due to central disc protrusion
and cause sensory (particularly posterior column) and motor dysfunction in the arms
and legs, and bladder and bowel symptoms.
36.2. The appropriate
diagnostic criteria is as follows:
The onset may be sudden or insidious. Neck pain is common,
especially at night and with the neck in extension. Neck motions are frequently
limited and cause an exacerbation of pain. The hallmark is arm pain and/or
paresthesia. The pain is often described as a sharp, shooting pain that
radiates from proximal to distal along the anatomic course of the nerve.
The Spurling test (neck extension and tilting the head toward
the painful arm followed by axial compression of the cervical spine) is often
positive. The neurological exam may be normal if compression is not too severe
or there may be weakness, sensory impairment and/or altered reflexes.
36.3. Appropriate
diagnostic tests and treatments are as follows:
a. In the face of
a typical history and physical examination, plain spine x-rays are indicated
since treatment may be altered if there are associated problems such as
ostephytes.
b. Non-operative
treatment:
1. Cervical
traction;
2. Cervical
collar may be used; not to exceed one week;
3. Use of
analgesics, mild relaxants, and non-steroidal anti-inflammatory drugs;
4.
Appropriate physical medicine referral to include physical agents;
exercise, and manipulation/mobilization; and
5.
Indications for inpatient admission:
A.
Inability to control pain; and
B.
Progressive neurological deficit.
c. Injured
workers with significant neurologic deficit, uncontrollable pain, or who fail
to improve after two to four weeks should be referred for consultation to a
surgeon who does cervical operations.
d. Neuro-Imaging
examinations:
1.
Myelography followed by CT scan with contrast medium in place.
Myelography with CT scan is the established test for evaluating the presence of
nerve root compression. To warrant treatment, abnormalities must relate to the
clinical problems of the injured worker. There is no reason to admit an injured
worker to a hospital overnight for a myelogram. Persistent post-myelogram
syndrome should be treated by hydration, caffeine, and/or blood patch as an
outpatient procedure;
2. MRI,
although occasionally it may not provide complete information about root
compression or bony anatomy; and therefore,
3. EMG and
nerve conduction velocity studies may be required to determine exact level of
compression and rule out peripheral nerve compression, but should be delayed 21
days from onset of symptoms.
e. Inappropriate
diagnostic tests and examinations:
1. Computed
tomography without myelographic dye, although this may be helpful for other
conditions such as infection or tumor;
2.
Myeloscopy;
3.
Dermatomal somatosensory evoked potentials;
4.
Thermography; and
5.
Spinoscopy.
f. Operative
treatment:
1. Failure
of non-operative treatment to relieve symptoms;
2. Quality
of injured worker’s life significantly impaired; or
3. Presence
of significant or progressive neurologic deficit, either radiculopathy or
myelopathy diagnosis confirmed by myelogram with CT scan, or by MRI.
g. Procedure
options:
1.
Laminectomy with excision of disc or arthritic spur or foraminotomy.
Fusion is not indicated for a simple disc. Discharge 2 - 4 days post op. Posterior
fusion is not indicated unless approved.
2. Anterior
cervical diskectomy, especially in cases where there is medial compression.
Discharge 1-3 days post op.
3.
Complicated - after wound infection, thrombophlebitis, spinal fluid
leak, or other significant complication has been controlled; and
4.
Additional physical and/or vocational rehabilitation may be required.
36.4. The estimated
duration of care is as follows:
a. Non-operative
treatment - if still symptomatic by six weeks, must be referred for surgical
consultation; and
b. Operative
treatment - depending on degree of neurological impairment and persistent pain.
If pain persists over three months after surgery, the injured worker should be
referred for multidisciplinary pain management. If a disabling neurological
deficit persists more than three months, vocational guidance should be
considered. If a fusion has been done, the injured worker may require short
and/or long term modified work.
§85-20-37. Treatment Guidelines:
Low Back Musculoligamentous Injury (Sprain/Strain).
37.1. Strains and
sprains are a common cause of acute low back pain encountered in the general
population. These injuries often are the result of the mechanical stresses and
functional demands placed on the low back area by everyday activities. Symptoms
are believed to be related to a partial stretching or tearing of the soft
tissues (muscles, fascia, ligaments, facet joint capsule, etc.) The conditions,
for the vast majority of injured workers, are of short duration and complete
recovery is the general rule. Most injured workers with a musculoligamentous
injury to the low back recover rapidly, with 50% to 60% of injured workers
recovering within one week.
37.2. The appropriate
diagnostic criteria consist of:
Onset of low back pain and paraspinal muscle spasm begins
either suddenly after the injury occurs or develops gradually over the next 24
hours. The pain is usually relieved by rest and aggravated by motion of the
back. The pain usually does not radiate below the knee, and the strain is not
accompanied by paresthesias or muscle weakness in the legs. Physical findings
include low back tenderness to palpation, loss of normal lumbar lordosis, and
spasm of the paravertebral muscles. Straight leg raising and other tests that
cause spinal motion may increase low back pain. The injured worker may stand
with a list to the side or in a flexed position. The neurological examination
and nerve root stretch tests usually are negative.
37.3. Appropriate and
inappropriate diagnostic tests and examinations are as follows:
a. Although the
diagnosis of a musculoligamentous injury is not based on radiographic criteria,
plain x-rays may be indicated based on mechanism of injury (actual trauma,
hyperextension, compression), a high index of clinical signs of pathology, or
treatment plan for manipulative therapy. Pain, which persists (no improvement)
longer than 2-4 weeks or worsens may also be criteria for x-rays.
b. Inappropriate
diagnostic tests and examinations during the acute phase of the first four
weeks:
1. CT scan;
2. MRI;
3. Bone
scans;
4.
Myelography;
5. EMG;
6.
*Thermogram;
7. *Evoked
Potentials;
8.
*Myeloscopy; and
9.
*Spinoscopy;
*Never appropriate
c. Failure to
improve in four weeks warrants an appropriate second opinion.
37.4. Treatment
considerations are as follows:
a. Non-operative
treatment:
1.
Indications: Almost all injured workers with low back musculoligamentous
(sprain/strain) can be treated satisfactorily. No indications exist for the use
of surgery in the treatment of low back musculoligamentous injuries.
2.
Treatment options:
A.
Short-term bed rest for approximately 2 days with appropriate
positioning;
B. Analgesics;
C.
Muscle relaxants as needed;
D.
Anti-inflammatory nonsteroidal medication;
E.
Referral for physical medicine (PT, OT, DC, DO, and physiatrist);
F.
Physical modalities in conjunction with proper body mechanics and
flexibility, endurance, and strength reactivation exercises;
G.
Manipulation of spine;
H.
Occasional trigger point injections; and
I.
Lumbosacral corset or brace.
b. Inappropriate
treatment:
1.
Operative treatment is inappropriate for low back strain;
2.
Prolonged bed rest beyond two days;
3. Narcotic
medication for prolonged period;
4. Home
traction; and
5.
Inpatient treatment.
37.5. The estimated
duration of care: 0 to 4 weeks; not to exceed 8 weeks.
37.6. A diagnosis of
sprain/strain exceeding this 8 week period requires detailed
re-evaluation. The Commission,
Insurance Commissioner, private carrier or self-insured employer, whichever is
applicable, may require an IME to verify the diagnosis and will authorize
continued treatment/coverage in its sole discretion.
37.7. The anticipated
outcome is resumption of normal activity without residual symptoms in most
cases. Transitional activities may be required.
37.8. Modifiers (age,
and co-morbidity). Co-morbidity (e.g.,
degenerative disc disease, spondylolisthesis, segmental instability,
osteoporosis, spine deformity) may be associated with a higher incidence of
persistent symptoms but are not compensable conditions.
§85-20-38. Treatment
Guidelines: Herniated Lumbar Disc.
38.1. Injured workers
under treatment by their own physician who fail to improve after two to four
weeks - refer to a qualified orthopedic surgeon or neurosurgeon for
consultation and/or treatment.
Herniations occur most commonly through a posterolateral
defect, but midline herniations may occur. Resulting compression of the spinal
nerve root causes inflammation and pain, usually along the anatomic course of
the nerve. In the lumbar spine, this most often occurs at the L4 and L5 disc
levels, causing pressure on the corresponding L5 and S1 nerve roots. As a
result of both mechanical and biochemical changes around the nerve root, the
injured worker will experience pain, paresthesia, and possibly weakness in the
leg or legs usually below the knee. The rare herniations at the L1, L2 and L3
levels are usually associated with pain, paresthesia, and weakness above the
knee. Back pain may or may not be a presenting complaint with any herniated
lumbar disc.
38.2. The appropriate
diagnostic criteria consist of:
Back pain is usually the first symptom and may or may not abate
as the pain and paresthesias begin to radiate down the leg. The leg pain is
often described as a sharp, shooting pain that radiates along the anatomic
course of the nerve from proximal to distal. The onset may be sudden or
insidious. The injured worker often has difficulty getting up from sitting or
supine positions and commonly leans or lists to one side or the other. Motion
of the spine is limited due to pain and muscle spasm. The neurological
examination may be normal if the compressed nerve is still functional, or it
may yield objective evidence of impaired nerve function (e.g. atrophy,
weakness, sensory alteration or diminished reflex) depending upon the nerve root
affected. Signs of nerve root tension (e.g. positive straight leg raising) may
also be present.
When the L4 disc herniates, it usually causes pressure on the
L5 nerve root resulting in weakness of the great toe extensor or other
dorsiflexor muscles of the foot and sensory loss along the medial aspect of the
foot to the great toe, but it is usually not associated with reflex
abnormality. When the L5 disc herniates, it usually causes pressure on the S1
nerve root, resulting in a sensory deficit in the posterior calf area and
lateral aspect of the foot in addition to a diminished Achilles’ reflex and
occasional weakness of the plantar flexors of the foot.
38.3. Diagnostic test
and examination considerations are as follows:
a. Clinical
diagnosis is supported by these studies:
1. Plain
spine radiographs (and on rare occasions bone scans) to rule out other
conditions such as tumor, infection, fracture and congenital anomalies, if not
previously done;
2. MRI; and
3.
Myelography with CT scans.
b. Inappropriate
diagnostic tests and examinations:
1.
Myeloscopy;
2.
Dermatomal somatosensory evoked potentials;
3.
Thermography; and
4.
Spinoscopy.
c. Supporting
evidence. EMG may be helpful in rare
cases. Discography can occasionally be helpful. Selective lumbar nerve block
may be helpful for diagnosis.
38.4. The appropriate
treatment is as follows:
a. Outpatient
treatment:
1.
Non-operative treatment:
A.
Short period of bed rest, up to 10 days with analgesics, mild relaxants,
and non-steroidal anti-inflammatory drugs;
B.
Physical medicine and/or rehabilitation; and
C.
Orthotics.
The value of periods of bed rest has not been
demonstrated. Complete bed rest for prolonged periods may be deleterious to the
body and should be closely monitored. A significant number of injured workers
will respond to a nonoperative treatment program for herniated lumbar disc. The
physician should be aware that those injured workers who have marked, early
limitation of straight leg raising and those injured workers who have symptoms
or physical findings suggestive of cauda equina syndrome may need early
surgery. Close monitoring is indicated in those settings.
b. Inpatient
treatment.
1.
Non-operative treatment.
A.
Indications for admission.
1. Inability to control pain; and
2.
Severe or progressive neurologic deficit.
B.
Treatment options.
1.
Monitored bed rest with parenteral medications.
C.
Indications for discharge.
1.
Uncomplicated - relief or improvement of leg and/or back pain.
2.
Exceptions:
(a) No response to nonoperative treatment options requiring
consideration of surgical intervention; and
(b) Spinal headache after myelogram requiring IV fluids or blood
patch.
2.
Operative treatment:
A.
Indications: diagnosis confirmed by myelography with CT scan, or MRI,
plus one of the following three.
1.
Failure of nonoperative treatment to relieve symptoms;
2.
Quality of injured worker’s life significantly impaired; and
3.
Presence of significant or progressive neurologic deficit.
B.
Procedure options:
1.
Open removal; and
2.
Percutaneous diskectomy by special approval.
C.
Indications for discharge:
1. Uncomplicated - One to three days
after diskectomy.
2.
Complicated - after wound infection, thrombophlebitis, spinal fluid
leak, or other significant complication has been controlled.
D.
Home health care may be required for a short period.
E.
Physical modalities and/or rehabilitative procedures.
1.
Some monitoring of the injured worker’s activities may be necessary;
2.
General fitness, flexibility, and simple spinal muscle strengthening are
all important;
3.
Injured worker should be instructed in walking program with a gradual
increase in physical activities; and
4.
Strengthening exercises or work simulation activities may be indicated
for some injured workers.
F.
Supporting evidence. Diskectomy
has been proven to be a safe and effective procedure in some injured workers
with herniated disc. Such surgical intervention remains elective (in the
absence of a severe neurologic deficit) and the decision is based on the
surgeon’s clinical judgment and the injured worker’s personal assessment of the
extent to which quality of life has been impaired.
38.5. The estimated
duration of care is as follows:
a. Nonoperative
treatment - maximum medical improvement 0 - 12 weeks.
b. Operative
treatment - 0 - 12 weeks.
38.6. Modifiers (age,
and co-morbidity). Injured workers with symptoms suggestive of cauda equina
syndrome will require a different approach to treatment. Cauda equina syndrome
is a surgical emergency. Symptoms include low back pain and paralysis with loss
of bladder and bowel control. Once this diagnosis is suspected, the injured
worker should undergo prompt referral and neurodiagnostic evaluation.
§85-20-39. Treatment
Guidelines: Lumbar Fusion.
39.1. Indications of compensable
lumbar fusion:
a. Injuries to
bone or soft tissue that cause instability;
b. For a second
or third time disc surgery, the injured worker must have a second medical
opinion and prior approval from the Commission, Insurance Commissioner, private
carrier or self-insured employer, whichever is applicable.
39.2. Lumbar fusion may
also be appropriate treatment for other noncompensable conditions for which
treatment will not be authorized:
a. Cancer;
b. Symptomatic
spondylolisthesis; and
c. Documented
instability for other cause.
d. Degenerative
disc disease with pre-operative documentation of instability.
e.
Pseudoarthrosis.
39.3. Contraindications
for lumbar fusion.
a. Primary
surgery for a new, acute disc herniation with unilateral radiation leg pain.
39.4. Surgical
procedures.
a. Bony fusion
with or without instrumentation. A
second concurring surgical opinion must be obtained before surgery unless clear
evidence of a medical emergency exist.
§85-20-40. Treatment
Guidelines: Shoulder Injury Guidelines.
40.1. The term
“shoulder complex” refers to the humerus, clavicle, scapula and the surrounding
supporting connective tissue and emphasizes their interdependent relationship.
Articulations of the “shoulder complex” are the sternoclavicular,
acromioclavicular, scapulothoracic, glenohumeral, and subacromial arch.
Fractures, separations, or subluxations/dislocations of
components within the “shoulder complex” result from trauma to the shoulder
girdle or upper extremity. Soft tissue strains or sprains may result from
either trauma or longstanding accumulative microtrauma. The rotator cuff is
particularly vulnerable to overuse pathology.
Treatment of “shoulder complex” injuries is directed to
restoring balanced motion in the entire complex. Because of the importance of
the soft tissues, physical therapy is very important and can be lengthy. On the
other hand, because the shoulder complex is so adaptable, most individuals can
find alternative patterns of function in their work, home, or recreational
needs while they are undergoing physical rehabilitation.
40.2. The appropriate
diagnostic criteria are as follows:
a. History and
physical.
1.
Mechanism of injury - single episode or repetitive microtrauma.
2. Pain
pattern - pain at rest, pain related to work, activities of daily living, or
recreational activities, night pain; painful arc of motion; position of
comfort; relative position of the pain; relative position of the neck; referred
pattern (pain below the elbow suggests a radicular component).
3.
Range-of-motion - active glenohumeral and scapulothoracic balance;
passive forward flexion, external rotation, internal rotation, and abduction
compared to the opposite side.
4. Palpation
- point or zone of maximum tenderness.
5.
Neurological - motor, sensory, muscle stretch reflexes for C5, C6, C7,
C8 and T1 roots.
6. Special
tests - apprehension; drop arm; impingement; Yergason; posterior apprehension;
sulcus sign; clunk; AC spring; Adson; Awinged scapular; lateral scapular slide.
40.3. The appropriate
diagnostic tests are as follows:
a. Routine
imaging:
1. Shoulder
series - internal, external, and transaxillary or transcapular lateral (a
transthoracic lateral is of no benefit except in humeral shaft fractures,
posterior dislocations of the shoulder may be missed).
2. Special
imaging - requires pre-authorization and specialty referral.
A. CT
scan;
B.
MRI;
C.
Arthrogram; and
D.
EMG/NCV.
40.4. The guidelines
for appropriate specialty referral are as follows:
a. Failure of
improvement or resolution of symptoms with conservative treatment in four
weeks;
b. Radiographic
evidence of fracture, subluxation, or dislocation;
c. Initial
presentation of hemarthrosis;
d. Significant
lack of motion compared to opposite side; and
e. Suspected
neurologic injury.
40.5. Appropriate
treatment is as follows:
a. Fracture -
subluxation/dislocation (requires specialty referral).
1.
Nonoperative or operative:
A.
One to four weeks of immobilization; and
B.
Physical therapy beginning in one to four weeks and continuing up to six
months.
b.
Sternoclavicular or acromioclavicular strain or grade 1 (non-displaced
sprain).
1.
Non-operative:
A.
One to seven days of immobilization;
B.
Physical therapy, modalities and range-of-motion, one to six weeks;
C.
Duration of care - one to six weeks;
D.
Anticipated results - resolution of symptoms and resumption of normal
activities. May develop degenerative arthritis at a later date.
2.
Operative (specialty referral) - no indication except evidence of
degenerative changes after prolonged conservative management.
c. Rotator cuff
tendinitis/bursitis.
1.
Nonoperative.
A.
Local steroid injections at three to six week intervals (not to exceed
three);
B.
Physical therapy - up to three months at decreasing intervals;
C.
Job activity modification if indicated; and
D.
NSAIDs.
2.
Operative (specialty referral).
A.
Indications.
1.
Failure of improvement after three to six months of conservative care;
2.
Positive impingement sign; and
3.
Arthrogram or MRI to determine integrity of rotator cuff.
B.
Physical therapy following surgery, three to six months at decreasing
intervals.
d. Rotator cuff
tear.
1. History
- sudden onset of pain and inability to initiate active abduction; passive
abduction relatively normal; plain x-rays revealed not acute bony changes.
2.
Nonoperative.
A.
Physical therapy one to three weeks;
B.
Specialty referral if no improvement.
3.
Operative (specialty referral).
A.
Arthrogram or MRI confirms tear; and
B.
Physical therapy following surgery, three to six months at decreasing
intervals.
e. Adhesive
capsulitis (frozen shoulder).
1. History
- insidious pain and loss of motion in the glenohumeral joint.
2.
Nonoperative.
A.
Physical therapy tried one to six weeks;
B.
Glenohumeral joint injection with saline distention using short acting
steroids plus Xylocaine - limit two at three week intervals; and
C.
Specialty referral if no improvement after six to eight weeks.
3.
Operative (specialty referral).
A.
Manipulation if no improvement after three months.
4. Other
conditions which (require specialty referral).
A.
Thoracic outlet syndrome;
B.
Brachial plexus injuries; and
C.
Ruptured biceps tendon, proximally or distally.
§85-20-41. Treatment
Guidelines: Carpal Tunnel Syndrome.
41.1. The purpose of
the Carpal Tunnel Syndrome (“CTS”) Rule is to provide the treating physician
with treatment guidance and treatment parameters so that the treating team can:
a. Determine if
the illness is work-related; that is, determine causality.
b. Properly
diagnose the illness through a careful history, physical examination and
appropriate diagnostic tests and examinations.
c. Initiate
timely and proper treatment; and
d. Keep the
injured worker in the workplace, through modified or restricted duty if
necessary, as much as possible during the treatment plan.
41.2. Background. CTS is one of several nerve
compression/entrapment syndromes of the upper extremity. This condition occurs when pressure
increases in the canal and disrupts the normal flow of nerve impulses to the
hand. The exact cause of this condition
is unclear. It is often bilateral. The prevalence of CTS in the general
population is approximately 3.1%. Half of
CTS cases are idiopathic. Providers
considering the diagnosis and compensability of CTS are advised to assess
several factors, diagnostic accuracy, confounding conditions, work setting and
duration of symptoms in assigning causality.
41.3. Diagnostic
Accuracy. Hand symptoms may be produced
by tendonitis, arthritis, tumor, interrupted
blood flow, trauma or nerve entrapment at levels from the neck to the
hand. Symptoms suggesting CTS include
numbness and paresthesia (especially at night), weakness, uselessness and pain
in a median nerve distribution.
Clinical examination findings are frequently difficult to
interpret. Tinel’s and Phalen’s tests
have limited sensitivity and specificity.
Thenar atrophy is a late sign.
41.4. Confounding
Conditions. Medical conditions
frequently produce or contribute to CTS.
Recognition of these conditions is important for good outcomes. Diabetes mellitus, hypothyroidism, obesity,
alcohol abuse, rheumatoid arthritis, postural abnormalities and other
conditions can precipitate CTS symptoms.
Pregnancy is a well-established risk factor for reversible CTS. Sleep disorders significantly aggravate CTS
for some patients. Hobbies and sports
activities may contribute to CTS symptoms.
A careful look for contributing noncompensable factors may impact
causality and response to treatment.
41.5. Work
Setting. Occupational groups at high
risk for CTS have included grinders, butchers, grocery store workers, frozen
food factory workers, manufacturing workers, dental hygienists, platers and
workers with high force, high repetitive manual movement. The literature notes a high prevalence of
concurrent medical conditions capable of causing CTS in persons with the
syndrome, without regard to any particular occupation. Studies have failed to show a relationship
between normal clerical activities and CTS.
When evaluating CTS in this work setting, a careful search for other
contributing factors is essential.
Awkward wrist positioning, vibratory tools, significant grip force, and
high force of repetitive manual movements have all been shown to contribute to
CTS. The Moore-Garg Strain Index is a
valuable tool for assessing risk for work-related CTS.
41.6. Duration. Work-related CTS is associated with years of
repetitive activity. To find CTS in
workers with weeks to months of exposure suggests a pre-existing condition.
41.7. Diagnosis
Criteria.
a. Pertinent
Historical and Physical Findings
1. Patients
usually complain of painful, burning paresthesia or numbness involving the
thumb, index, long and occasionally radial aspect of the ring digit or the
entire hand.
2. These
symptoms are usually worse while lying down or sitting quietly.
3.
Activities such as driving, holding a telephone or fixing one’s hair
often precipitate the paresthesia.
4. The most
common complaints usually include nocturnal paresthesia, clumsiness with loss
of fine dexterity and dropping things.
5. The
patient often feels as if there is a loss of circulation. The paresthesia is often relieved by
actively working the fingers, shaking the hand or holding it in a dependent
position.
6. Pain is
usually present over the palmar wrist area and may radiate proximally as far as
the shoulder or neck.
7. Findings
are consistent with those of a nerve irritation.
A.
Tinel’s test may be positive over the medial nerve in the proximal palm
or wrist.
B.
Numbness in the fingers may be elicited with the wrist in extreme
extension or flexion (Phalen’s test).
C.
There may be decreased sensation distal to the wrist, particularly over
the thumb, index and middle fingers, inability to flex or oppose the thumb or
abduct it in its own plane and thenar muscle atrophy.
D.
There can be significant variations in location of pain and sensory
changes.
E.
The examiner also needs to evaluate additional or alternate sites of compression that can produce
similar symptoms.
b. Appropriate
Diagnostic Tests and Examinations
1.
Radiographs of the hand and wrist if indicated by history and
examination, mainly in patients with history of previous trauma or painful
range of motion of the wrist.
2. Nerve
conduction studies and electromyograms. (Mild cases wait 6 weeks).
3. Response
to conservative measures; splinting of wrist and carpal tunnel steroid
injections.
4.
Laboratory studies if symptoms suggest an underlying disease such as
diabetes mellitus, thyroid dysfunction or rheumatoid arthritis.
5.
Radiograph of cervical spine, upper extremity and/or chest if symptoms
suggest a more proximal disease process.
c. Specialist
Directed Tests and Examinations
1. CT scan
and MRI only if indicated by previous plain films and history pace-occupying
deformity or mass.
2. Wrist
arthrogram if findings suggestive of carpal instability.
d. Supporting
Evidence.
1. Since
double crush syndrome (entrapment of a nerve at more than one level) and
systemic diseases causing carpal tunnel syndrome are not unusual, a thorough
evaluation is essential.
2. EMG/NCS
is the standard diagnostic modality and has high sensitivity and
specificity. Regarding EMG and NCS,
there is variability in the skill of the testing physician and diagnostic
reference criteria do vary. This should
be carefully monitored by the referring physician and by a Quality Assurance
mechanism.
41.8. Treatment.
a. Non-operative
Treatment
1.
Indications
A.
Symptoms mild or moderate (but without thenar atrophy).
B.
Pregnancy or other systemic problems that may be treated medically.
C.
Onset of symptoms associated with work exposure, and plausibly subjective and/or objective findings.
D.
Associated with other physical conditions, i.e. cervical radiculopathy.
2.
Treatment.
A.
Initial Four Weeks -- Options
1.
Splint wrist in neutral.
2.
Nonsteroidal anti-inflammatory drugs.
3.
Steroid injections, optional.
4.
Eliminate or modify aggravating activities with the cooperation of the
employer.
5.
Physical medicine.
6.
Concurrent treatment of systemic disease until the injury has returned
to pre-injury status.
7.
Self care: ice, elevation, range of motion, stretching, exercises,
postural correction, etc.
3. Referral
A. If
there is no substantial improvement by four (4) weeks, the injured worker
should be referred for evaluation and possible treatment.
B.
Treatment should be by either a
physical medicine practitioner or a
surgeon (orthopedic, hand, plastic, or
neurosurgeon).
1. Physical Medicine.
(a) A physical medicine practitioner shall evaluate for functional
anatomical lesions in the neck, shoulder, thorax, elbow and wrist. Physical medicine examiners: Chiropractor
(DC), Osteopathic Physician (DO who specializes in manipulation), Physical
Medicine and Rehabilitation Specialist (MD/DO, formerly known as “physiatrist”), Physical Therapist (PT), and
Occupational Therapist (OT).
(b) If functional anatomical lesions are identified, two to eight
(2-8) weeks of treatment with a
physical medicine practitioner (DC, DO who specializes in manipulation, MD/DO
who is a physical medicine and rehabilitation specialist, PT, OT) should be
performed on a decreasing frequency.
The referring physician shall be provided progress reports at 2-week
intervals. Treatment should cease if
two weeks pass without significant documented functional improvement. It is important that the injured worker continue to work and
perform his or her activities of daily living during this therapy. Modified duty or work reassignment is
appropriate during treatment.
b. Ambulatory
Surgery.
1.
Indications
A.
Unresponsive or progression of symptoms in the face of non-operative
treatment; objective signs.
B.
Thenar atrophy or objective impairment of sensibility (widened two-point
discrimination or diminished light touch).
C.
Intolerable numbness and pain.
D.
Mass or deformity in carpal tunnel.
2.
Treatment Options
A.
The operative treatment usually includes minimal invasive type of
surgery vs. open type of surgery, and is indicated according to the condition
of the patient.
B. In
some of the severe CTS cases, the surgeon may wish to seek an examination by
another physician in order to determine if the injured worker is an appropriate
candidate for recovery and return to work.
3. Home
Health Care. When self-care is
compromised during the early post-operative period, homemaker services may be
required in some instances.
Examples: opposite hand amputation
or limiting injury.
4. Physical
Rehabilitation.
A.
Brief post-operative splinting, optional.
B.
Finger and wrist range of motion.
C.
Scar massage after sutures removed.
D.
Grip and pinch strengthening.
E.
Range of motion exercises of affected extremity.
F.
Progressive activity reintroduction.
G.
Physical medicine, if indicated, should be limited to six weeks.
5.
Supporting Evidence.
A.
Carpal tunnel release relieved pain and paresthesia in up to 90% of
patients with correct diagnosis.
B.
Significant pre-operative median nerve
involvement, concurrent medical conditions and/or inability to
modify aggravating exposures may affect
post-operative functional recovery.
c. In-Patient Treatment.
1.
Inpatient Treatment.
A.
Rare.
B.
Associated with other trauma or condition, i.e. crush injury, burns,
etc.
2.
Indications for Admission.
A.
Compartment syndrome of forearm.
B.
Other serious medical conditions which increase surgical anesthetic
risks.
C.
Complication at time of operative procedure.
D.
Treatment options: same as for ambulatory patient.
E.
Indications for discharge:
medical condition stabilized.
F.
Home health care: same as for
ambulatory patient.
G.
Rehabilitation: same as for ambulatory patient.
d. Estimated
Duration of Care
1.
Non-operative Treatment
A.
Activity modification may be indicated.
B.
Depending on objective findings and past duration of symptoms and as
outlined in the Presley Reed Guide referenced in this Rule.
2.
Operative Treatment
A.
Consistent with global guidelines and as outlined in the Presley Reed
Guide referenced in this Rule.
B.
Three month follow-up unless there are complicating factors.
e. Anticipated
Outcome.
1. Improved
sensory and/or motor and/or autonomic function.
2.
Elimination of paresthesia.
3.
Lessening of pain.
4. In
severe carpal tunnel syndrome cases, complete relief of the symptoms is usually
not obtained. The surgery is performed
to stop progression of the nerve damage or to delay progression of damage
already present in the form of nerve fibrosis and vascular changes.
f. Modifiers
1. Pregnant
and nursing women usually have decreased or resolved symptoms shortly after
delivery or cessation of lactation, but persistent symptoms may require
surgical release.
2. Age and
gender are not modifiers.
3.
Co-existent neurological or systemic disorder, i.e. diabetes,
thyroid dysfunction, amyloidosis, etc.,
may make symptoms more severe and less likely to fully resolve following
treatment.
g. Cold laser is
an experimental and unproven therapy.
The Commission, Insurance Commissioner, private carrier or self-insured
employer, whichever is applicable, will not pay for such treatment.
41.9. Rehabilitation
a. Keeping
Workers on the Job.
1. Workers
generally are in a more positive psychosocial, motivational and financial mode
when they continue to work. These
factors impact significantly on the rehabilitation outcome.
2. Barring
a clear medical contraindication, if the employer can provide suitable
reasonable accommodations based upon restrictions recommended by the physician
due to the compensable medical condition, the injured worker should continue to
work during the recovery process and be released to return to such work as soon
as possible when temporary disability is unavoidable.
b. The Work
Release
1. Return
to work may be initiated via two paths, starting with the physician’s work
release or with a proposal from the employer or a qualified rehabilitation
professional.
2. In
either case, the release must be as specific as possible so the employer and
patient clearly understand what is expected.
The physician should address:
A.
Physical restrictions, time restrictions (hours per day and/or week
and duration of the restriction).
B.
Pacing restrictions.
C.
Break requirements (frequency and purpose, such as for rest from certain
activities, icing, warm-up exercise, self-massage, etc.).
D.
Recommended job site
accommodations (such as workstation height or set-up)
or ergonomic devices (such as anti-vibration tool wraps).
3. When the
employer or a qualified rehabilitation professional offers a return to work
proposal, the attending physician should expect to be provided:
A. A
functional job analysis with which to make an informed decision regarding the work release. The job analysis must thoroughly describe
job duties, physical demands (strength and production/work pace), tools used
and environment.
B.
Assurance that the employer (line supervisors and co-workers, not just
human resources personnel) will support the worker in the restricted or
alternate duty return to work.
C. A
rehabilitation plan signed by the employer, injured worker and a qualified
rehabilitation professional when restricted or alternate duty (part-time or full-time) is to be
approved. This plan should describe the
accommodations being offered and the time frame for which they will be
available.
c. Career
Changes. Injured workers with
significant permanent upper extremity residual impairment will frequently need
a permanent change of vocations.
d. The provisions
of Section 41.9 may be used to govern the rehabilitation processes of injuries
other than carpal tunnel syndrome as appropriate.
§85-20-42. Treatment
Guidelines: Injuries to the Knee.
42.1. The vast majority
of knee injuries result from direct trauma to the joint or are caused by
torsional or angulatory forces. These injuries vary in severity from simple
ligamentous strains to complex injuries involving ligamentous disruption with
meniscal damage and associated fracture. This guideline is designed to guide
the practitioner in the appropriate management of these injuries and to
establish a logical sequence for the diagnostic evaluation and treatment of the
more complex injuries.In general, knee injuries should be referred for
orthopedic consultation and/or treatment under the following circumstances:
a. Failure of a
presumed knee sprain to show progressive resolution and respond to appropriate
conservative treatment in a period of three (3) weeks;
b. Radiographic
evidence of an associated fracture;
c. The initial
presence of a tense hemarthrosis or the development of a recurrent
hemarthrosis;
d. An acutely
locked or an acutely dislocated knee;
e. Clinical
evidence of gross ligamentous instability; and
f. A presumed diagnosis
of a meniscal injury.
§85-20-43. Treatment
Guidelines: Knee Sprains.
43.1. These are common
injuries resulting from the application of a torsional or angulatory force to
the knee and are characterized by pain, mild swelling, localized tenderness,
increased discomfort or weight bearing, negative x-rays, and no clinical
evidence of instability.
a. The
appropriate diagnostic tests.
1. Plain
x-rays.
43.2. The appropriate
and inappropriate treatment is as follows:
a. Nonoperative
treatment.
1.
Medications to include nonnarcotic analgesics and nonsteroidal
anti-inflammatory drugs;
2.
Application of ice, compression dressings, and temporary partial
restriction of weight bearing;
3. Physical
modalities and/or rehabilitative procedures;
4. Duration
of care - estimated duration of care is three weeks, not to exceed six weeks;
and
5.
Anticipated result - resolution of symptoms and resumption of normal
activities.
b. Inappropriate
treatment:
1. Surgery;
2.
Inpatient; and
3. Greater
than three weeks without consultation.
§85-20-44. Treatment
Guidelines: Meniscal Injuries.
44.1. The mechanism of
injury is similar to that for knee sprains but symptoms of pain and swelling
fail to resolve in the anticipated period of time and the symptoms frequently
include a sensation of “catching or giving away” of the joint and a history of
locking of the joint may be elicited.
Clinical findings may include joint space tenderness, a mild
effusion and restricted range-of-motion and positive McMurray’s sign.
44.2. The appropriate
diagnostic tests are as follows:
a. Plain x-rays;
b.
Arthrocentesis;
c. MRI;
d. Arthrogram;
and
e. Diagnostic
arthroscopy.
44.3. The appropriate
treatment is as follows:
a.
Outpatient/nonoperative treatment.
1.
Short-term use of nonsteroidal anti-inflammatory drugs in conjunction
with an arthrocentesis and short-term immobilization with a period of limited
weight bearing;
2. Physical
modalities and/or rehabilitative procedures.
b.
Outpatient/operative treatment.
1. Options
include arthroscopic meniscectomy and/or arthroscopic meniscal repair; and
2. Physical
therapy/rehabilitation.
c.
Inpatient/nonoperative treatment not indicated.
d. Inpatient
operative treatment - The reasons for admission for surgical treatment may
include the presence of associated medical conditions, a concomitant knee
injury such as a fracture of the tibial plateau or a major ligamentous
disruption, or the presence of other injuries which require inpatient
treatment.
44.4. The duration of
treatment may vary up to three (3) months. The injured worker’s age and
pre-existence of arthritic changes within the joint will influence the duration
of treatment.
44.5. The anticipated
outcome is as follows:
a. Improved knee
function with minimal residual symptoms; and
b. Possible
predisposition to the development of traumatic arthrosis of the knee.
§85-20-45. Treatment
Guidelines: Foot and Ankle Injuries.
45.1. Injuries to the
foot and ankle usually relate to a specific traumatic event and have a
predictable clinical course depending on the severity index of the initial
injury. For simplicity, injuries will be discussed relative to the anatomic
region of the foot and ankle (ankle, hind foot, midfoot, forefoot or
phalanges).
45.2. The appropriate
diagnostic criteria is as follows:
a. Pertinent
historical and physical findings:
1. Onset of
pain and/or swelling is related to a single event, either a twisting injury,
fall or direct blunt trauma. The degree of the injury can be judged quickly by
determining which one can bear weight and the degree of initial swelling. The
more severe injuries will have greater swelling, inability to bear weight, and
may have obvious deformity.
45.3. Diagnostic test
and examination considerations are as follows:
a. If
differentiation between a soft tissue ligamentous injury and a fracture is
required, x-rays in several planes are appropriate in all cases;
b. CT scans may
be indicated in hind foot injuries to define subtle fractures, tarsal
coalitions or the degree of displacement in three planes in acute injuries;
c. Bone scans are
occasionally indicated in long standing pain problems to rule out stress
fracture or inflammatory causes of foot pain (after four weeks of pain with
normal X-rays).
d. MRI rarely
indicated - should require specialty consultation; and
e. EMG and
vascular studies (non-invasive arterial perfusion or arteriography at the request
of the specialist).
f. Inappropriate
diagnostic tests:
1.
Thermogram.
g. Indications
for specialty referral:
1.
Displaced fractures;
2.
Neurovascular compromise; and
3. Pain and
swelling greater than three weeks.
45.4. The appropriate
treatment is as follows:
a. Non-operative.
1. Sprains
(No fracture seen on x-ray)
A.
Rest, ice compression and elevation(RICE);
B.
Crutches and splinting (one through three days);
C.
Early mobilization as pain allows. This may involve active supervised
physical therapy;
D.
Usual course - several days to three weeks; and
E.
Referral to specialist required if no improvement by three weeks.
2.
Fractures.
A.
Simple non-displaced:
1.
Ankle -- Specialty referral - Will require special
splinting or casting for three to six weeks and may require an additional two
to four weeks of physical therapy rehabilitation.
2.
Hind foot - Same as ankle.
3.
Midfoot - Same as ankle but course is usually two to four weeks shorter.
4.
Forefoot - Specialty referral not required special shoe or cast may be
necessary. Usually resolved in three to six weeks.
5.
Phalanges - Same as forefoot, simple taping and/or modified shoe usually
all that are necessary.
3.
Displaced fractures. Specialty
referral is mandatory. Non-operative treatment requires casting for three to
six weeks followed by up to four weeks of rehabilitation.
b.
Operative. All operative
decisions require specialty referral.
1.
Sprains. Indicated when there is
a complete dislocation/ subluxation without a fracture anywhere in the ankle,
hindfoot, or midfoot. May be indicated in the forefoot.
2.
Fractures.
A.
Simple - may be indicated in ankle.
B.
Displaced - Usually indicated in ankle, hindfoot, midfoot, and forefoot.
Displaced phalange fractures can sometimes be treated non-operatively.
§85-20-46. Treatment
Guidelines: Physical Medicine.
46.1. Principles for
use of physical medicine:
a. Physical
medicine should be initiated as early as the day of injury; indications for and
focus of (early) intervention include:
1. Acute
management of pain and spasms;
2. Use of
passive modalities as adjunct to active treatment;
3. Manual
therapy for restoring joint function;
4.
Instruction in range of motion and stretching exercises;
5.
Assessment of return to work readiness and identifying necessary work
modifications;
6. Injured
worker education in healing process, body mechanics, proper resting positions,
and home treatment program; and
7. Time
frames may range from one visit to daily visits in accordance with applicable
treatment guidelines.
b. Evaluations
and treatments authorized by the Commission, Insurance Commissioner, private
carrier or self-insured employer, whichever is applicable, must be provided by
professionals licensed to perform such activities.
c. Initiation of
treatment may not be indicated when:
1. Few
objectively measured deficits are found on evaluations;
2.
Subjective complaints of pain are the only finding;
3. Pain
behaviors are interfering with the return to work process; and
4. Injured
worker is not compliant with the treatment plan.
d. Inappropriate
and medically unsupported treatment is the exclusive use of passive modalities
throughout the course of treatment.
e. Exercise
programs are progressively increased to include strengthening and conditioning
exercises. Any work simulation activities (also gradually increased) should
focus on essential work tasks (pushing, pulling, lifting, etc.). Time frames
may range from 1 to 4 hours per day, 3 to 5 days per week in accordance with
above treatment guidelines.
f. Progress
reports to the referring physician, the Commission, Insurance Commissioner,
private carrier or self-insured employer, whichever is applicable, and the
employer should identify continuing complaints, progress made, further
rehabilitation needs, and level of return to work readiness. An injured worker
may continue in therapy, if indicated, after return to work in accordance with
applicable treatment guidelines.
46.2. Treatment
limitations. Physical medicine
treatment shall not exceed 10 visits in the initial 14 days and must decrease
in frequency thereafter. In no case
shall the treatment exceed 16 visits in the initial 30 days or 12 visits in the
second 30 days.
46.3. If physical
medicine care continues to the 30th day and the injured worker has
not returned to work, the treating physician may arrange a consultation for a
second opinion. Reimbursement for care
past the 45th day shall be disallowed unless the consulting
physician recommends further care.
46.4. If care continues
to the 30th day and the injured worker lost no time or is back to
work, shows significant documented functional and clinical signs of
improvement, and has not reached maximum medical improvement, continued care is
appropriate. Such care shall not exceed
the 60th day unless otherwise expressly authorized by this Rule.
46.5. Injured workers
with complicating factors which have prevented a return to work by the 60th
day require active case management by the Commission, Insurance Commissioner,
private carrier or self-insured employer, whichever is applicable, within the
parameters of this Rule. Independent
medical evaluator guidance may be requested by the Commission, Insurance
Commissioner, private carrier or self-insured employer, whichever is
applicable, in its sole discretion.
46.6. Treatment beyond
28 dates of service (within 60 days) is limited to a maximum of 5 treatments
over one additional 30-day period and requires Commission, Insurance
Commissioner, private carrier or self-insured employer, whichever is
applicable, authorization.
Authorization requires the worker has a history of surgery or fracture
in the involved area, and either 1) the worker has returned to work or 2)
modified work is not available.
46.7. Workers who have returned to work, reached
maximum medical improvement and experience flare-ups of their injuries, due to
job-related activities, may be treated a maximum of 4 times over a 2-week
period. The Commission, Insurance
Commissioner, private carrier or self-insured employer, whichever is applicable,
will reimburse a maximum of 12 treatments for work related flare-ups within 14
months of the date of injury.
46.8. Reimbursement
shall be disallowed for any treatment rendered after the injured worker reaches
maximum medical improvement unless otherwise expressly authorized by this Rule.
§85-20-47. Treatment
Guidelines, Protocols and Procedures for Performing Audiological Examinations
and Evaluations in Workers’ Compensation Claims for Noise-Induced Hearing Loss.
47.1. Only audiometric
test results obtained by an audiologist having a certificate of clinical
competence in audiology (CCC-A) or a West Virginia audiology licensure are
acceptable for purposes of awarding compensation. An audiogram performed at the request of any physician may be
utilized by the injured worker for the purpose of completing the workers’
compensation application form. However,
only physicians who are qualified otologists or otolaryngologists may interpret
the results of audiograms in assessing the degree of the injured worker’s
noise-induced hearing loss impairment for the purpose of determining the
percentages of the injured worker’s whole person impairment, if any.
47.2. A physician
examining and evaluating an injured worker in a noise-induced hearing loss
claim must consider the injured worker’s medical and occupational history, as
well as available audiograms, in determining the etiology of the hearing
loss. It is not necessary to use a
uniform brand and model of audiometer.
For Commission, Insurance Commissioner, private carrier or
self-insured employer, whichever is applicable, standards, the audiologist
shall adopt the ANSI Guidelines and
perform an annual exhaustive calibration.
The audiologist should also perform a daily listening check.
47.3. Establishing a
definitive margin of error: Two
audiograms are said to be in acceptable test-retest variability when the
total of four frequencies (500, 1000, 2000, 3000 Hz) is 15 decibels or less and
the audiometric curves are similar.
Because the two audiograms are technically identical and one cannot be
chosen over the other, the calculation of whole person impairment will be based
on the audiogram that yields the highest degree of impairment for the injured
worker.
a. If two
audiograms are both rated “good”, and
differ by more than the established margin of error, the Commission, Insurance Commissioner, private carrier or
self-insured employer, whichever is applicable, shall arrange for a third
independent evaluation by an otologist or otolaryngologist.
b. The two
audiograms that are within an acceptable test/retest variability should be
used.
47.4. The audiologist
shall be required to perform the following specific reliability and validity
checks during the course of an audiogram:
a. Speech
Reception Threshold (SRT)/Pure Tone Average Comparison: SRT should be within 10 decibels of the best
two frequency average for the pure tone thresholds of 500, 1000, 2000 Hz.
b. Both
ascending and descending thresholds
should be obtained at 1000 Hz for each ear.
The difference should be no greater than 5 decibels.
c. Reliability
should be rated: good, fair, poor.
d. Certified
and/or licensed audiologists must perform the audiogram.
e. The four
validity and reliability checks set forth above must be documented on the
Workers Compensation form and the examiner must initial his or her findings on
the forms.
47.5. The Commission,
Insurance Commissioner, private carrier or self-insured employer, whichever is
applicable, will inform all physicians evaluating noise-induced hearing loss
injured workers on the Commission’s, Insurance Commissioner’s, private
carrier’s or self-insured employer’s, whichever is applicable, behalf that
standard air conduction and bone conduction testing, speech reception
threshold, speech discrimination, tympanometry and acoustic reflex testing must
routinely be performed as a part of audiometric evaluation. Other testing, including otoacoustic
emission testing, may be required at the discretion of the
otologist/otolaryngologist. If the
required audiometric tests have not been done, the report is unacceptable and
the physician will not be compensated.
W. Va. Code §23-4-8.
47.6. When a
sensorineural hearing loss is present it may be the result of noise induced
hearing loss and/or other disease processes.
The medical evaluator should consider all causes of sensorineural
hearing loss. When a conductive loss is
present, the bone conduction levels will show the purist hearing an injured
worker could have as a result of noise
induced hearing loss.
47.7. The audiologist
shall perform speech discrimination (word recognition) testing using W-22 word
lists. Both live voice and recorded
presentation methods for testing speech discrimination are acceptable; each
method has its advantages. The
audiologist should use the method that provides the best representation of the
injured worker’s true speech discrimination score.
The otologist or otolaryngologist interpreting the speech
discrimination results shall use the formula set forth in W. Va. Code §23-4-6b,
to calculate the injured worker’s impairment rating.
47.8. Occupational
noise induced hearing loss (NIHL) typically starts in the high frequencies;
usually 3000, 4000 or 6000 Hz. With
progression, these frequencies worsen and the hearing loss extends to the lower
frequencies; (2000 and 1000 Hz). Even
with progression, however, the audiometric pattern remains one that descends
from the low frequencies to the high frequencies, sometimes with recovery at
6000 or 8000 Hz. Occupational NIHL does
not cause an ascending audiometric pattern (where the low frequencies would be
worse than the high frequencies). A
flat audiometric curve is also not typical of an etiology of solely
occupational NIHL. If an audiogram
presents a pattern that is atypical of an occupational NIHL pattern, then the
physician interpreting the audiogram should consider causes other than
occupational noise exposure in determining the hearing loss etiology. If the
otologist/otolaryngologist determines that an injured worker’s hearing loss is
not all noise induced hearing loss, he or she should estimate the true noise
induced hearing loss thresholds and explain his or her calculations on the
basis of medical and audiological findings.
47.9. When an injured
worker has been exposed to steady state noise, his or her NIHL will usually be
symmetrical between both ears. If the
injured worker has a hearing loss that is asymmetric then the evaluating
physician should consider all causes for hearing loss, including nonoccupational
noise, trauma or disease processes and whether there is more noise exposure on
one side than the other.
47.10. If a physician
determines that an injured worker’s hearing loss is the result of occupational
noise exposure, the total hearing loss impairment rating shall be calculated
pursuant to the formula set forth in W. Va. Code 23-4-6b.
47.11. The Commission,
Insurance Commissioner, private carrier or self-insured employer, whichever is
applicable, will reimburse for hearing aids when 5% or greater permanent industrial hearing loss impairment
has been diagnosed. The recommendation
for the hearing aid must be based on the evaluation of an otologist or a
otolaryngologist for reimbursement. The
Commission, Insurance Commissioner, private carrier or self-insured employer,
whichever is applicable, shall retain sole discretion to select the hearing aid
most appropriate for treatment.
§85-20-48. Reserved.
§85-20-49. Treatment
Guidelines: Multi- Disciplinary Pain Management.
49.1. It is now well
accepted that chronic pain treatment is a complex problem that involves
physical, emotional and behavioral components.
Chronic pain and treatment therefore, including multidisciplinary
interventions, is only compensable if specifically diagnosed as caused by an
injury received in the course of and resulting from employment.
49.2. Multidisciplinary
treatment for chronic pain and related disability has been more rigorously
examined than most other treatments used with chronic pain. There is strong evidence for the importance
of the behavioral/psychological component of treatment in making meaningful
changes in pain intensity, functional status and emotional distress.
49.3. The best
predictors of disability and response to multidisciplinary treatment may not be
a function of physical or medical variables; instead, psychological variables
may be the best predictors in certain cases.
Additionally, assessment of psychosocial “risk factors” for chronic
disability done shortly after injury can lead to more effective management by
identifying which patients are likely to benefit from multidisciplinary
treatment.
49.4. Chronic Pain
Syndrome: Chronic Pain Syndrome
patients are defined by the following criteria: a) Reports of persistent (i.e., at least four months duration) pain,
which may be consistent with or
significantly out of proportion to physical findings; b). Demonstrates or has demonstrated a
progressive deterioration in ability to function at home, socially and at work;
c) Shows or has shown a progressive increase in health care utilization (such
as repeated physical evaluations, diagnostic tests, requests for pain
medications and/or invasive medical procedures); d) Demonstrates mood
disturbance; and e) May exhibit clinically significant anger, frustration
and/or hostility.
49.5. Program
Guidelines:
a. Program
Goal: To address behavioral barriers,
which inhibit return to work while increasing physical function in a
protocol-based rehabilitation program.
b. If an injured
worker is diagnosed with Chronic Pain Syndrome directly related to a
compensable injury, any authorized pain management program shall contain the
following objectives and guidelines.
1. To
successfully return the patient to pre-injury work. If this goal is not realistically obtainable, then the goal is to
have the patient demonstrate specific alternative work capabilities.
2. To
develop work-related skills with work simulation activities.
3. To
develop strength, endurance, movement, flexibility and motor control related to
performance of specific vocational and avocational goals.
4. To
identify and improve management of psychosocial barriers to facilitate return
to work.
5. To
demonstrate increased responsibility for their condition through the use of
self-management techniques related to pain and associated psychological
symptoms. This should be done with
minimal ongoing medical intervention (decrease dependence on health care
system).
6. To
demonstrate understanding safe job performance, injury prevention and physical
and psychosocial threats to relapse.
c. Program
Direction: Responsibility should be
assigned for program direction and for medical direction. The same individual may be responsible for
both functions. Program direction need
not be provided by a physician. Program
Director may be an Allied Health Professional with an advance degree and state
licensure appropriate to degree.
Program Director must have at least one year’s experience in
interdisciplinary rehabilitation and participate in annual continuing education
in this field. The participating
physician must be board certified or eligible with annual continuing education
in this field.
d. For an injured
worker to be authorized to participate in a pain management program, the
injured worker must demonstrate: 1) At least three months of ongoing
pain-related temporary total disability or inability to safely return to
work; 2) The need for such a program
must be related to the compensable injury and subsequent consequences.; 3)The
patient should be able to express a vocational goal whether related to return
to work or retraining for return to work; and 4) Presence of psychosocial
barriers to rehabilitation (such as depression, anxiety, fear/avoidance
behaviors, poor coping/adaptation skills, anger).
e. Pain
management program shall not be authorized if any of the following factors
exist: 1) Presence of concurrent noncompensable health or mental health
condition that would prohibit full understanding and participation in the
program; 2) Medical instability that may warrant continued medical intervention
(such as surgery, etc.); or 3) Presence of a substance addiction/dependence
that prohibits safe and effective participation in the program.
f. Scope of
Service/Program Organization: CPS
patients are best treated in an integrated interdisciplinary program. The program needs to maximize continuity of
care by employing a coordinated group of health care professionals (i.e.,
physicians, psychologists, physical and occupational therapists, vocational
evaluators, counselors and specialty consultants) who evaluate and treat the
patient as a team.
g.
Evaluation: The treatment plan
is developed through an interdisciplinary evaluation with a recommendation for
either admission into the occupational rehabilitation program (ORP) or
appropriate alternative treatment. The
evaluation should consist of the following: 1) Review of records; 2)
Quantitative evaluation by physical therapist to determine current level of
functioning and anticipated outcome; 3) Psychological evaluation by licensed
psychologist to identify behavioral barriers to return to work and to determine
need for psychological intervention, if necessary; and 4) Medical evaluation by
a licensed physician to identify any medical barriers to participation and to
clear patient for physical restoration activity.
h. Treatment:
Individual treatment plan will address the following:
1.
Frequency and Intensity of the program:
The frequency, intensity and duration of the program should be
sufficient to demonstrate improvement in the following areas: work capabilities, strength, stamina and
psychosocial barriers to improved functioning (may include fear avoidance,
depression, anxiety, coping strategies, anger…) In order to achieve these goals
through an interdisciplinary approach and simulate a typical work day, this
treatment requires a minimum of five (5) and a maximum of eight (8) hours per
day, five (5) days per week. Daily
attendance is therefore imperative and integrated into the goals of the program
(see section 7). Provision of services
will include both daily behavioral/psychological and physical restoration
activities. Effective outcome from
interdisciplinary treatment is usually accomplished within a maximum of 20
treatment days. Thus, this 20
treatment-day upper limit for intervention with CPS patients is recommended;
2.
Extensions To Treatment:
Occasionally, there may be justifications for extended treatment beyond
the 20-day program. Any such extension
needs to be documented, time-limited and monitored on a case-by-case
basis. The following should apply to
potential extension situations: 1) The
patient has clearly shown significant and objectively documented progress
within the initial 20-day treatment protocol; 2) Further functional gains that
increase the patient’s likelihood to return to work are likely within the
extension period; 3) Extension periods
should be time limited and should not exceed 10 treatment days.
i. Treatment Team
Members:
1. Services
should be provided by a coordinated interdisciplinary team that includes a core
team of individuals who are specifically assigned to the program. The following disciplines, and others as may
be designated by the program director, shall constitute the core treatment
team: participating physician, clinical
psychologist and physical therapist.
2.
Dependent on the needs of the patient, the following practitioners may
also be involved: case manager
(internal or external), psychiatrist, nurse, occupational therapist, vocational
specialist.
j. Services
Provided: Services shall include, but not be limited to: 1) Medical assessment;
2) Weekly staff meetings that include the core treatment team (or their
assigned representatives).; 3) Ongoing reappraisal of each participant’s
clinical and functional work status; 4) Performance of appropriate medical
diagnostic and treatment procedures; 5) Providing information needed to assist
participant to return to work; 6) The practice, modification and instruction of
component work tasks through real or simulated work; 7) The development of
strength and endurance of the participant related to the performance of work
tasks; 8) education to teach safe job performance and prevent re-injury; 9) Promotion
of self-management strategies; and 10) The development of attitudes and
behaviors that will improve the ability of the participant to return to work or
benefit from other rehabilitation.
k. Space: Services consistent with the needs of the
program shall be provided in settings as follows: 1) A physical therapy setting
that allows for conditioning and strength training. An area that supports a work-related treatment environment, which
would include work simulation activities, is also needed; 2) Classroom and
conference space is required for individual counseling and educational
sessions.; and 3) The program may be provided as a private or group practice,
hospital based program or freestanding program. All services provided should ideally be performed at a single
campus setting. Services should not be
performed at more than two locations within a given treatment day.
l. Documentation:
1. Whenever
possible, pain management programs shall offer outpatient rather than inpatient
services and clear and convincing documentation proving that outpatient
treatment is inappropriate in a particular claim is required before inpatient
treatment can be authorized.
Documentation of interdisciplinary evaluation prior to admission shall
include: a) A quantitative report by a licensed physical therapist that
documents current level of functioning and anticipated outcome; b) A
psychological report by a licensed psychologist that documents behavioral
and/or emotional barriers to return to work and identifies the need for
psychological intervention (if necessary); c) Medical report that documents any
barriers to participation in the program and gives medical clearance for the
patients participation in physical restoration activity; and e) Post-evaluation
summary report that documents specific treatment recommendations.
2.
Treatment documentation should include at a minimum: a) Daily progress
notes; b) Weekly Staffing Summaries which document progress toward goals,
current functional status, and newly identified barriers to participation; and
c) Discharge Summary which documents progress achieved in functional,
work-related goals, work capability at discharge, progress in addressing
psychological barriers to improved function, medical status, and recommendations. The Commission, Insurance Commissioner,
private carrier or self-insured employer, whichever is applicable, will
determine the standards by which this will be reported and the timeframe for
such reporting.
m. Discharge
Criteria: Discharge of a participant
from an interdisciplinary rehabilitation program shall be based upon the
following: 1) Goals of the program have been achieved; 2) The injured worker
has failed to fully participate and/or comply with program requirements; 3) The
physician of record has discontinued the program for the participant; 4) A
condition has arisen directly related to the compensable injury requiring
further medical or other health care intervention, not present at initiation of
the program.; 5) Prior to completion of the program, it is determined by the
service provider or attending physician that the client will be unable to
accomplish the goals of the program.
This determination can be based upon a combination of objective and subjective
criteria; and 6) The participant has excessive absences.
§85-20-50. Treatment
Guidelines: Interventional Management of Chronic Pain.
Definitions:
As used in this exempt legislative rule, the following terms
have the stated meanings unless the context of a specific use clearly indicates
another meaning is intended.
50.1. “Acute pain”
means pain experienced as the result of injury, disease, or operative
procedure. Treatment usually consists
of medications, surgical repair, and/or physical medicine therapies. Care may be provided in the office, clinic,
or hospital setting.
50.2. “Bier block”
means the instillation of medication into the venous system of a limb for
anesthetic or therapeutic purposes; venous circulation is occluded with a
tourniquet to retain medication in the veins of the limb.
50.3. “Chronic pain”
means pain lasting more than three months.
The cause of the pain is often unknown and may not be linked to an
actual physiological event. Chronic
pain complaints are usually accompanied by other psychophysiological disorders
such as depression, weight gain or loss, sleep disorder and digestive
disorder. A nurse case manager must
coordinate care for claimants experiencing chronic pain, including intervention
by a pain management specialist early in the treatment process and involvement
of other treatment modalities and consultative specialists as needed.
50.4.
“Interdisciplinary” means including representation from two or more
health care fields.
50.5. “Medical Services
Unit” or “Office of Medical Services” means a group of Commission, Insurance
Commissioner, private carrier or self-insured employer, whichever is
applicable, personnel designated to deal with health care issues; such
personnel may be supplemented with health care personnel providing services on a
contract or other basis.
50.6. “Nerve block”
means injection of a local anesthetic medication in proximity to a nerve or
nerve plexus to block nerve transmission.
50.7. “Nurse Case
Manager” means a duly licensed registered professional nurse authorized by the
Commission, Insurance Commissioner, private carrier or self-insured employer,
whichever is applicable, to coordinate health care and rehabilitative services
for injured workers.
50.8. “Pain” refers to
a complex unpleasant sensory and emotional experience associated with actual or
potential tissue damage or which may just be a subjective experience described
in terms of such damage.
50.9. “Pain management
specialist” means a licensed physician with specialized training and experience
in the diagnosis and/or treatment of chronic pain.
50.10. “Steady dose”
refers to the amount and frequency of pain relief medication that is required
to maintain optimum pain relief, once the dosage of such medication has become
fixed or nearly fixed in amount and frequency.
50.11. “Trigger point
injection” means placement of a needle into a myofascial space with or without
injection of medication.
General:
50.12. All
practitioners who treat chronic pain need to address goals in three major life
areas: physical; social; and
psychological.
a. Physical goals
include: analgesia, early mobility,
functional restoration and increased exercise tolerance, strength and range of
motion.
b. Social goals
include: a positive expectation for
recovery from family and support systems; avoiding identification with disabled
family prototypes; resistance to the negative reinforcement from interested
other parties; and recognition of the deleterious effects of the disability
lifestyle.
c. Psychological
goals include: dealing with grief and
loss over altered function and coping with chronic distress and a changed
lifestyle; maintaining a positive attitude toward recovery; focusing
motivation; appreciating primary, secondary and tertiary gains; and obtaining
diagnosis and treatment for any psychiatric diagnosis.
50.13. Emergency
conditions such as Complex Regional Pain Syndrome (Reflex Sympathetic
Dystrophy) may require immediate consultation with a pain specialist and
initiation of treatment without delay.
50.14. In contusion and
sprain/strain cases, and in non-surgical disk cases, claimants who are being
considered for injections for the treatment of chronic pain, but who have not
had a trial of physical medicine, including exercise and/or manipulation, will
be required to be evaluated by a physical medicine practitioner or other
independent medical evaluator. The
physical medicine practitioner or other evaluator will determine whether a
30-day regimen of physical medicine in conjunction with initiation of chronic
pain therapy is likely to provide full or partial relief prior to initiating a
series of injections.
50.15. When chronic
pain patients do not respond to initial specialist-directed efforts, a nurse
case manager may be assigned to coordinate the pain management effort. The nurse case manager’s or other case
manager’s report will include an assessment as to the benefits of chronic pain
management, such as the likelihood that the claimant will be able to return to
work. A psychiatric or psychological
evaluation must be part of the assessment process. Psychiatric conditions must be evaluated and under treatment as
indicated before use of long-term narcotics or implantable devices will be
authorized by the Commission, Insurance
Commissioner, private carrier or self-insured employer, whichever is
applicable.
50.16. Claimants who
have injuries greater than six (6) months old with continued symptoms, and who
are not actively being treated for chronic pain may be eligible for an
additional six (6) months further treatment or management of pain, only if an
independent medical evaluator selected by the injured worker’s treating
physician agrees that the recommended treatment, including pain management, is
reasonable, necessary, related to the compensable injury, and likely to be
successful in substantially reducing the injured worker’s symptoms.
Injections:
The following criteria must be met before the Commission,
Insurance Commissioner, private carrier or self-insured employer, whichever is
applicable, will authorize the use of injections by the pain management
specialist form the treatment plan:
50.17. The Claim file
must document objective physical signs and subjective symptoms which support
the use of the proposed procedure.
50.18. When performing
a “series” of injections, there must be documentation of measurable physical,
psychological or vocational improvement before performing the next
injection. Treatment of low back pain
requires that a complete Commission, Insurance Commissioner, private carrier or
self-insured employer, whichever is applicable, back form be in the injured
worker’s file.
50.19. Active, not
passive, physical medicine and home exercises prescribed after documented
demonstration to the prescribing provider are to be a part of any injection or
procedure-based treatment plan. A
report from the provider must be sent to the physician and a copy to the claims
manager after every fourth visit. If physical
medicine is not recommended, the physician must explain why it is not going to
be used. Pain management shall be
terminated if the injured worker fails to fully cooperate with the required
exercise program.
50.20. If a surgical
spine lesion exists that shows no immediate neurologic danger, cervical
epidural steroids may be considered prior to surgery. The surgeon and the pain management specialists should work
collaboratively in such cases. If
epidural injections fail to provide relief or if new neurological deficits
develop, surgical, evaluation should be scheduled promptly. The treating physician is responsible for
referring any suspected surgical lesion promptly to a surgeon.
50.21. The treatments
under each of the following categories are deemed appropriate. The order in which the treatments within
each category are listed is not controlling of the treatment plan except as
indicated.
Head and Neck Pain:
50.22. Peripheral
Nerves, including occipital, greater and lesser, auricular, supraorbital,
maxillary branch of V, mandibular branch of V, and others.
a. Six (6) blocks
over three (3) months in office, or in ambulatory clinic if fluoroscopy is
required;
b. Neurolysis/
Denervation by cryotherapy, chemical means, radiofrequency, or surgical
intervention if good response not substained.
50.23. Facial Pain
Sympathetically maintained
a. Sphenopalatine
ganglion block-six (6) blocks over three (3) months;
b. Stellate
ganglion block-six (6) blocks over three (3) months
50.24. Intrathecal
Opioids- if all other conservative treatments fail
a. A trial is
required. Refer to specific guidelines.
b. A second
opinion is required before implant.
50.25. Myofascial Pain
a. Trigger point
injections, no more than six (6) points or no more than six (6) occasions in
three (3) months. If authorization for
trigger point injections are requested more than twice in 1 year or 4 cycles
total, the claim may be assigned a
nurse case manager. Authorization is at
the discretion of the Commission, Insurance Commissioner, private carrier or
self-insured employer, whichever is applicable, after review of the case and
focus on the claimant’s work record.
b. Home exercise
and physical medicine is required in combination with trigger point injections.
50.26. Cervical Facet
Mediated Pain.
a. No more than 4
injections over six (6) months.
b. Physical
medicine is required in combination with injections.
c. Neurolysis/
Denervation by cryotherapy, chemical means, radiofrequency or surgical
intervention if good response to anesthetic injections not sustained.
50.27. Cervical
Radiculopathy
a. Cervical
epidural steroids, no more than four (4) injections in a six (6) month period,
if surgery in accordance with the appropriate Workers’ Compensation treatment
guideline is not a medically viable option or if surgery has been attempted and
failed to provide relief;
b. Cervical
epidural infusion
c. If physical
medicine alone fails in 30 days, suprascapular nerve block should be
considered.
d. Spinal cord
stimulation if other treatments fail. See specific guidelines.
Shoulder And Upper Extremity:
50.28. Adhesive
Capsulitis.
a. Physical
medicine alone should be used initially;
b. If physical
medicine alone fails, distention by injection or a local nerve block may be
performed combined with a follow-up exercise program.
50.29. Subdeltoid
Bursitis, Olecranon Bursitis- No more than three (3) injections over six (6)
months.
50.30. Epicondylitis -
No more than three (3) injections over six (6) months.
50.31. Myofascial Pain
a. Trigger point
injections, no more than six (6) points or no more than six (6) occasions in
three (3) months;
b. If trigger
point injections need to be repeated more than twice in (one) 1 year or for
more than four (4) cycles total, a nurse case manager will be assigned to the
claim. Authorization is at the
discretion of the Commission, Insurance Commissioner, private carrier or
self-insured employer, whichever is applicable.
c. Home exercise
and physical medicine is required in combination with trigger point injections.
50.32. Phantom pain or
stump pain.
a. Stellate
ganglion block, up to six (6) times over a three (3) month period;
b. Cervical
epidural catheter with infusion, for not more than four (4) weeks;
c. Spinal cord
stimulation per specific guidelines if the above therapies fail.
50.33. Complex regional
pain syndrome (reflex sympathetic dystrophy)
a. Referral to
specialist made immediately upon diagnosis;
b. Cervical
epidural infusion in conjunction with a program of physical medicine therapy no
more than four (4) weeks duration;
c. Spinal cord
stimulation in accordance with specific guidelines;
d. Stellate
ganglion block, up to twelve (12) times during a three (3) month period;
e. Bier block, up
to six (6) times over a three (3) month period.
50.34. Peripheral nerve
injury
a. Nerve block,
up to six (6) times over a three (3) month period;
b. Bier blocks up
to six (6) times over a three (3) month period;
c. Cervical
epidural infusion with physical
medicine therapy of no more than four (4) weeks duration;
d. Spinal cord
stimulation in accordance with specific guidelines.
50.35. Carpal Tunnel
Syndrome
a. Nerve block up
to six (6) times over a three (3) month period, if surgery in accordance with
the Commission’s, Insurance Commissioner’s, private carrier’s or self-insured
employer’s, whichever is applicable,
treatment guideline is not a
medically viable option or if surgery has been attempted and failed to provide
relief.
50.36. Other Causes of
Extremity Pain
a. Treatment on a
case by case basis, subject to review by the Commission, Insurance
Commissioner, private carrier or self-insured employer, whichever is
applicable.
Thoracic and Chest Wall Pain:
50.37. Thoracic Disc
Syndrome
a. Thoracic
epidural steroids injection, up to four (4) times over six (6) months, if
surgery is not a medically viable option, in the sole discretion of the
Commission, Insurance Commissioner, private carrier or self-insured employer,
whichever is applicable, or if surgery has been attempted and failed to provide
relief.
b. Thoracic
epidural infusion, accompanied by physical medicine if epidural steroids fail.
50.38. Intercostal
Neuralgia
a. Intercostal
nerve block with local steroids, up to four (4) times over six (6) months;
b. Thoracic
epidural steroids, up to four (4) times over six (6) months;
c. Neurolytic
intercostal injection if good but nonsustained improvement with steroid
injections;
d. Spinal cord
stimulation as per specific guidelines.
50.39. Costochondritis
a. Injection of
joint, up to four (4) times over six (6) months;
b. Concurrent
treatment by physical medicine is required.
Abdominal Pain:
50.40. Traumatic
pancreatitis
a. Celiac plexus
blocks, up to six (6) times over six (6) months;
b. Neurolytic
celiac plexus blocks if a good but unsustained response results from celiac
plexus blocks with local anesthetic;
c. Intrathecal
opioids. See specific guide lines.
50.41. Post Hernia
Nerve Entrapment-Injection of involved nerve, up to six (6) times over three
(3) month period
50.42. Peripheral nerve
involvement
a. Injection of
ilioinguinal, genitofemoral, iliohypogastric, or other peripheral nerves, up to
six (6) times over (3) months
b. Spinal cord
stimulation in accordance with specific guidelines.
50.43. Pelvic/ Rectal/
Penile/ Vulvar pain
a. Superior
hypogastric plexus block, up to four (4) times over a three (3) month period;
b. Intrathecal
opioids – see specific guidelines
c. Peripheral
nerve block as approved by the Commission, Insurance Commissioner, private
carrier or self-insured employer, whichever is applicable.
Low back-Lumbar pain:
50.44. Lumbar Facet
Joint Syndrome
a. Injections of
facets, up to four (4) times over a six (6) month period, with physical
medicine or home exercise. If this
needs to be repeated more than twice in a one (1) year or for more than four
(4) cycles total, a nurse case manager will be assigned to the claim. Authorization for continued treatment
is at the discretion of the Commission, Insurance Commissioner, private carrier
or self-insured employer, whichever is applicable.
b. Neurolysis/
Denervation by cryotherapy, chemical means , radio-frequency, or surgical
intervention if complete pain relief following injections is not
sustained.
50.45. Sacroilitis
a. Injection of
joint with a local anesthetic and steroid, up to four (4) times over a six (6)
month period.
50.46. Piriformis
Syndrome
a. Injection of
muscle with a local anesthetic and/or steroid, in conjunction with physical
medicine. No more than four (4)
injections over a six (6) month period.
50.47. Post Laminectomy
Syndrome/ Adhesive Arachnoiditis/ Spinal Stenosis/ Failed Fusion/ Intractable
Radiculopathy/ Coccydynia.
a. Lumbar or
caudal epidural steroids, up to four (4) injections over six (6) months.
b. Spinal cord
stimulation as per Commission, Insurance Commissioner, private carrier or
self-insured employer, whichever is applicable, guidelines;
c. Intrathecal
opioids as per Commission, Insurance Commissioner, private carrier or
self-insured employer, whichever is applicable, guidelines;
d. Trigger point
injections, no more than six (6) points or no more than six (6) occasions in
three (3) months.
50.48. Myofacial pain
a. Trigger points
no more than six (6) points or no more than six (6) occasions in three (3)
months.
Lower Extremity:
50.49. Lumbar
radiculopathy
a. Lumbar
epidural steroids, up to 4 injections over a 6 month period, in conjunction
with physical medicine, if surgery in the opinion of the Commission, Insurance
Commissioner, private carrier or self-insured employer, whichever is
applicable, is not a medically viable option or if surgery has been attempted
and failed to provide relief. If this
needs to be repeated more than twice in 1 year or 4 cycles , a nurse case
manager may be assigned to the claim.
Authorization for continued treatment is at the sole discretion of the
Commission, Insurance Commissioner, private carrier or self-insured employer,
whichever is applicable.
b. Documented
interval improvement.
c. Spinal cord
stimulation as approved by the Commission, Insurance Commissioner, private
carrier or self-insured employer, whichever is applicable.
50.50. Complex Regional
Pain Syndrome (Reflex Sympathetic Dystrophy)
a. Referral to
specialist immediately upon diagnosis.
b. Lumbar
sympathetic plexus block, up to 12 times over a 3 month period;
c. Lumbar epidural
infusion with analgesic agents, in conjunction with physical medicine, for up
to 4 weeks;
d. Bier block, up
to 6 injections over a 3 month period;
e. Spinal cord
stimulation as approved by the Commission, Insurance Commissioner, private carrier
or self-insured employer, whichever is applicable.
50.51. Phantom Limb
Pain/ Stump Pain
a. Lumbar
sympathetic plexus block, up to 6 injections over a 3 month period.
b. Lumbar
epidural infusion with analgesic agents, in conjunction with physical medicine
therapy, for up to 4 weeks
c. Spinal cord
stimulation as approved by the Commission, Insurance Commissioner, private
carrier or self-insured employer, whichever is applicable.
50.52. Peripheral Nerve
Injury, including saphenouse, femoral or sciatic nerves
a. Nerve block,
up to 6 injections over a 3 month period;
b. Bier block, up
to 6 injections over a 3 month period;
c. Lumbar
epidural infusion with analgesic agents, in conjunction with physical medicine,
for up to 4 weeks;
d. Spinal cord
stimulation as approved by the Commission, Insurance Commissioner, private
carrier or self-insured employer, whichever is applicable.
50.53. Greater
Trochanteric Bursitis
a. Up to 3
injections with a local anesthetic and a steroid over a 3 month period.
50.54. Meralgia
Paraesthetica
a. Injection of
lateral femoral cutaneous nerve with a local anesthetic agent, up to 6
injections over a 3 month period.
50.55. Myofascial Pain
a. Trigger point
injections, no more than 6 points or no more than 6 occasions in 3 months.
50.56. Other Causes Of
Extremity Pain
a. Treatment will
be authorized by the Commission, Insurance Commissioner, private carrier or
self-insured employer, whichever is applicable, in it’s sole discretion, on a
case by case basis.
Cancer Pain:
Injury related causality must be established prior to
authorization for pain management. A
nurse case manager may be assigned to claims involving treatment of cancer
pain. Unlike treatment for other types of pain,
intrathecal opioids for treatment of cancer pain will not require
psychiatric evaluation or a second opinion.
50.57. Long-Term Opioid
Use: the use of long-term oral, rectal, or transdermal opioid therapy in the
non-malignant injured worker is complex and should only be considered in
selected injured workers, including, but not limited to, injured workers with
diagnoses of failed back surgery syndrome, Complex Regional Pain Syndrome
(Reflex Sympathetic Dystrophy), inoperable spinal lesions and spinal stenosis,
or plexopathies. Other diagnoses will
be considered by a case by case basis, but only as a treatment option of last
resort. The following factors are to be
addressed in writing in any report recommending the use of long-term opioid
therapy:
a. If low dose
opioid therapy has not provided at least partial analgesia, then long-term
opioid therapy is not an option.
b. The goal of
long-term opioid therapy is not complete analgesia. The efficacy of long term opioid therapy is measured by
improvement in the injured worker’s social and physical function.
c. This therapy
should be considered only after all other reasonable attempts at analgesia have
failed. Opioid therapy should never be
a first line treatment.
d. A history of
substance abuse in the injured worker or his or her family (alcohol or other
drugs), even if remote, should be regarded as a relative contraindication. If a history of substance abuse is obtained
and the choice to long-term, opioid therapy is made despite such history, an
appropriate consultation and plan to prevent relapse must be in place before
prescribing of opioids.
e. Pregnant
injured workers are not candidates for long-term opioid therapy. Female injured workers of child-bearing age
are to be advised of the risks to a fetus should pregnancy occur during opioid
therapy.
50.58. If the decision
is made to initiate long-term opioid therapy, the following must be part of the
program:
a. Psychiatric –
A psychiatric evaluation of the injured worker for psychiatric disorders and
potential for substance abuse must precede the decision to carry out long-term
opioid therapy, and a copy of the evaluation must be submitted with the request
to initiate opioid therapy.
b. A written
contract between the injured worker and the pain management specialist must be
established at the onset of the long-term drug therapy. The injured worker must agree that (1) a
single practitioner will be responsible for prescribing all medication for pain
control; (2) the injured worker will not obtain prescriptions from providers
other than the pain management specialist; (3) after an initial six month
period of initial dose titration, only one dose escalation per three month
period will be allowed; and (4) the
injured worker will not consume alcohol or other medications except as approved
by the pain management specialist. Any
material violation discovered may cause immediate drug tapering and
discontinuation of opioid maintenance therapy.
c. Initial
long-term opioid therapy must be prescribed by a pain management specialist;
once therapy has reached the “steady dose” level, the attending physician may
resume medical management;
d. The injured
worker will be monitored by a nurse case manager during the period when a
“steady dose” is being established; the pain management specialist or the
attending physician must reevaluate the injured worker every 60-90 days after
the “steady dose” has been reached.
e. Injured
workers must give informed consent before long-term opioid therapy is
initiated; consent must include recognition of the risks of psychological
dependence, cognitive impairment and long-term physical side-effects.
f. In order for
long-term opioid therapy to continue, there must be documentation of improvement
in the social and physical functions, as assessed and documented through home
visits by a nurse case manager, written documentation must be provided to the
attending physician and pain management specialist. Specific assessment tools must be used such as interview of
significant others, pain drawing comparisons, quality of life and social
functioning checklist comparisons.
g. Reassessment
by a pain management specialist selected by the Commission, Insurance
Commissioner, private carrier or self-insured employer, whichever is
applicable, will be done annually for injured workers maintained on opioids.
h. Every year,
the Commission, Insurance Commissioner, private carrier or self-insured
employer, whichever is applicable, must review the treatment plant to determine
the appropriateness of care. The
Commission, Insurance Commissioner, private carrier or self-insured employer,
whichever is applicable, may call for more frequent review if the use of narcotic
medication increases.
i. Evidence of
acquisition of opioids from other physicians or persons, uncontrolled increases
in dose requirements, drug hoarding, abuse of alcohol or other drugs,
conviction of a crime related to drug possession or trafficking, or other
behaviors in violation of the narcotic contract should be followed by immediate
drug tapering and discontinuation of opioid maintenance therapy.
50.59. Implantable
Devices: Use of intrathecal pumps and
spinal cord stimulators will only be authorized when other treatments of extremity,
back or neck pain, such as pharmacological, physical, or psychological therapy,
have failed.
a. The procedure
is undertaken only after physical and psychiatric or psychological
screening. Psychological or psychiatric
clearance will be performed to rule out any untreated psychiatric or behavioral
problems and to enhance the efficacy of the device.
b. In the absence
of a documented physiological problem, authorization for implantable pain
control devices is at the discretion of the Commission, Insurance Commissioner,
private carrier or self-insured employer, whichever is applicable.
c. An untreated
substance abuse problem prior to implementation of the proposed device will be
sufficient reason to deny the request for the implantable device,
notwithstanding other physical or psychological criteria.
d. An implantable
device will not be authorized until a second opinion is given by a physician
with credentials to implant similar devices.
The second opinion may be based upon a review of the injured worker’s
file, or by an independent medical evaluation; either evaluation must be
documented in writing. The referral of
the injured worker or claim file for the second opinion must be arranged
through the Commission, Insurance Commissioner, private carrier or self-insured
employer, whichever is applicable,.
50.60. Procedure Guides
for Implantable Devices.
a. Implementation
of devices will be authorized only at facilities which meet the following
criteria: (1) a physician trained in residency of by the “hands-on” continuing
medical training will perform the procedure; (2) all technical support,
computers, and ancillary personnel, and a “stand-by” surgical specialist deemed
necessary for the specific case must be in place before the procedure begins.
b. The implanting
physician will be responsible for all management of the implantable device
until such time that another physician credentialed in the management of like
devices accepts the injured worker.
c. The necessary
“in-home” support must be authorized by the Commission, Insurance Commissioner,
private carrier or self-insured employer, whichever is applicable, and
scheduled prior to implantation of the device.
d. Both
intrathecal pumps and dorsal column stimulators must have a successful trial
period before the permanent device is placed.
The trial period for the pump will be no less than two days. The trial period for the stimulator will be
no less that three days as an outpatient.
There must be at least a 50% reduction in subjective pain rating and
objective improvement in ability to engage in functional activities.
50.61.
Contraindications for Implantable Devices: The following are contraindications for an implantation:
a. Allergies or
hypersensitivity to the drug being used;
b. Life
expectancy of less that three (3) months;
c. Body size is
insufficient to support weight and bulk of the device;
d. Less than 50%
relief is seen with trial stimulation or intrathecal device;
e. The injured
worker does not perceive the trial implantation as pleasant, or side effects
are intolerable;
f. The injured
worker has an active coagulopathy;
g. The injured
worker has a localized or disseminated infection;
h. The injured
worker has a demand cardiac pacer or may need one relatively soon (for
stimulator only);
i. The injured
worker has an untreated substance abuse problem;
j. A significant
psychological or behavioral contraindication has been identified;
k. The physician
requesting the procedure is not adequately trained or experienced in the
procedure;
l. Appropriate
surgical coverage necessary to handle any complications is not available before
beginning the procedure.
50.62. Myeloscopy in
Chronic Pain Management – Myeloscopy procedures are to be reviewed on a case by
case basis by the Commission, Insurance Commissioner, private carrier or
self-insured employer, whichever is applicable, before authorization can be
considered.
§85-20-51. Treatment
Guidelines: Complex Regional Pain Syndrome.
51.1. Background:
Complex regional pain syndrome (CRPS) is a descriptive term encompassing
a variety of painful conditions following injury, which appear regionally and
have a distal predominance of abnormal physical examination findings. This painful condition typically follows a
traumatic injury or noxious event to an extremity, with a disproportionate
response respective to the original insult.
Medical conditions including stroke and myocardial infarction may also
be precipitating factors. The pain
pattern is not limited to the distribution of a single peripheral nerve, and
physical findings include edema, alterations in skin blood flow, abnormal
sudomotor activity in the region of pain, allodynia or hyperalgesia. Treatment for CRPS is only compensable if
directly caused by an injury received in the course of and resulting from
employment.
51.2. CRPS Type I
(Reflex Sympathetic Dystrophy).
a. Type 1 CRPS is
a syndrome that may develop after an initiating noxious event.
b. Spontaneous
pain or allodynia/ hyperalgesia occurs, but is not limited to the territory of
a single peripheral nerve and is disproportionate to the inciting event.
c. There is or
has been evidence of edema, skin blood flow abnormality, or abnormal sudomotor
activity in the region of the pain since the inciting event.
d. The diagnosis
is excluded by the existence of conditions that would otherwise account for the
degree of pain and dysfunction.
51.3. CRPS Type II
(Causalgia).
a. Type II CRPS
is a syndrome that develops after a nerve injury. Spontaneous pain or allodynia/hyperalgesia occurs and is not
necessarily limited to the territory of the injured nerve.
b. There is or
has been evidence of edema, skin blood flow abnormality, or abnormal sudomotor
activity in the region of the pain since the inciting event.
c. The diagnosis
is excluded by the existence of conditions that would otherwise account for the
degree of pain and dysfunction.
51.4. Diagnostic
Criteria:
a. History of a
noxious event or cause of immobilization.
b. Continued
pain, allodynia or hyperalgesia out of proportion to the injury.
c. Physical
evidence of edema, trophic skin changes, hair loss, alterations in skin blood
flow or abnormal sudomotor activity in the region of pain.
d. The diagnosis
is excluded by the existence of conditions that otherwise account for the
degree of pain and dysfunction.
51.5. Diagnostic
Studies.
a. Surface
temperature measurements indicating at least 1 degree Celsius asymmetry between
the normal and injured sides. The
existence of a skin temperature differential may vary, and repeated
measurements are helpful. The injured
side may be warmer or cooler.
b. A three-phase
radionuclide bone scan may assist in diagnosis. A normal study does not exclude this diagnosis, however.
c. Radiographic
studies of the injured extremity may show patchy demineralization in some
cases.
51.6. Treatment: Treatment for compensable complex regional
pain syndrome type 1 (reflex sympathetic dystrophy) should be directed at
providing pain control in an effort to promote participation in a directed
physical and/or occupational therapy program to restore use and function of the
injured extremity. Treatment options
include:
a. Pharmacologic Agents.
1.
Nonsteroidal anti-inflammatory drugs.
2.
Tricyclic antidepressants.
3.
Anticonvulsants.
4. Oral
opioids.
5. Oral
steroids.
b. Physical
Modalities.
1. Range of
motion exercises (passive, active assisted, active).
2.
Weight-bearing exercises.
3.
Edema-control garments (stocking or glove).
c. Injection
Techniques.
1. Somatic
and sympathetic nerve blocks.
d. Surgical
Sympathectomy. Surgical sympathectomy
is rarely considered effective in resolution of complex regional pain
syndromes. These syndromes, including
causalgia and reflex sympathetic dystrophy, are related to receptor
supersensitivity, and are not caused by over-activity of the sympathetic nervous
system. Most patients undergoing a surgical
sympathectomy obtain only transient improvement in pain levels, and may suffer
serious or disabling complications from the surgery.
51.7. The assistance of
a pain management psychologist or psychiatrist may be helpful in providing
motivational support, assessing and treating co-existing conditions such as
depression, and may aid in the establishment of realistic treatment goals and
objectives.
51.8. This condition
may be appropriate for treatment in a multidisciplinary program.
§85-20-52. Procedure in
Occupational Pneumoconiosis Cases.
52.1. A properly
completed application must be received before the potential claim will be
considered by the Commission, Insurance Commissioner, private carrier or
self-insured employer, whichever is applicable. A properly completed application must include 1) a completed
WC-105 form; 2) a completed WC-205
form; 3) an ILO form properly completed by a certified “B” reader; and 4) a
listing of all alleged exposures to harmful dust, including type of dust, and
extent and duration of exposure with each named employer.
52.2. If the employer
submits credible evidence demonstrating that it has been in compliance with
OSHA and/or MSHA permissible exposure levels, as determined by sampling and
testing performed in compliance with OSHA and/or MSHA regulations for the dust
alleged by the injured worker, then the Commission, Insurance Commissioner,
private carrier or self-insured employer, whichever is applicable, may consider
that the dust exposure alleged by the injured worker does not suffice to
satisfy the exposure requirements of W. Va. Code §§23-4-1(b) and 23-4-15(b)
only for the period(s) covered by the sampling or testing. In order for the evidence to be deemed
credible, it must be based upon regularly scheduled exposure samples from each
work area where harmful exposure has been alleged, which samples will be
obtained by certified industrial hygienists as defined by OSHA and/or MSHA
regulations or government agencies, and the samplings must be obtained during the
period for which the employer is seeking to avoid chargeability. The employer shall provide to all parties
to the claim all discoverable communications to and from the industrial
hygienist, and the entire test file, including the results of the industrial
hygienist. In the absence of other
relevant evidence, periods for which injured workers can demonstrate by
credible evidence that the employer’s sampling and test results do not
accurately reflect conditions in the injured worker’s work areas shall be
included by the Commission, Insurance Commissioner, private carrier or
self-insured employer, whichever is applicable, for the period of dust exposure
which the claimant has alleged to be harmful.
52.3. Nonmedical
hearing.
Upon receipt of a proper application, employer's reports and
investigation (if requested by the Commission or Insurance Commissioner,
whichever is applicable), the Commission or Insurance Commissioner, whichever
is applicable, shall determine the nonmedical questions, and shall notify all
interested parties of the decision; Provided, in cases where a self-insured
employer or private carrier is not requesting allocation, the self-insured
employer or private carrier shall enter the nonmedical order. A properly completed application must be
filed or the application shall be rejected. -- After the Commission, Insurance
Commissioner, self-insured employer or private carrier, whichever is
applicable, makes or has made a determination, any dissatisfied party may,
within thirty (30) days after receipt of written notice of the Commission's,
Insurance Commissioner’s, self-insured employer’s or private carrier’s,
whichever is applicable, decision, file objection thereto in writing, whereupon
the Office of Judges will set a time and place for a hearing thereon. These hearings shall be subject to the
provisions of the rules promulgated by the Office of Judges (Title 93, Series
1).
Upon completion of the nonmedical hearing, the Office of Judges
will enter a final nonmedical ruling and shall notify the injured worker and
employer of this decision. The Office
of Judge’s final nonmedical ruling will be subject to appeal to the Workers'
Compensation Board of Review.
52.4. Occupational
pneumoconiosis board hearing.
Following issuance by the Commission or Insurance Commissioner,
whichever is applicable, of a ruling on the nonmedical issues, the Commission,
Insurance Commissioner, private carrier or self-insured employer, whichever is
applicable, shall refer this claim to the Occupational Pneumoconiosis
Board: Provided That, the requirements
of W. Va. Code §23-4-15b have been satisfied.
In the case of such reference, the Commission, Insurance Commissioner,
private carrier or self-insured employer, whichever is applicable, will notify
the injured worker to appear before the Board for an examination and shall
state the date, time, and location thereof.
The Commission, Insurance Commissioner, private carrier or self-insured
employer, whichever is applicable, will notify the employer or employers of the
date, time and place of the examination.
A quorum of the Board will then proceed to hear and determine all
medical questions relating to the claim.
At such hearing the injured worker and each employer must
produce as evidence all reports of medical and X ray examinations that may be
in their respective possession or control showing the past or present condition
of the employee.
52.5. Report of
Occupational Pneumoconiosis Board.
Upon completion of the hearing the participating members of the
Occupational Pneumoconiosis Board shall prepare a written report to the
Commission, Insurance Commissioner, private carrier or self-insured employer,
whichever is applicable, setting forth their findings and decision, and shall
prepare a sufficient number of signed copies of report so that the Commission,
Insurance Commissioner, private carrier or self-insured employer, whichever is
applicable, may file one in his office, send one to the injured worker and one
to each employer interested in the claim.
52.6. Objections.
Any interested party who objects, in whole or in part, to the
findings and conclusions of the Board may, within the statutory period after
the mailing to him of the copy of the report, or within such additional time as
may be allowed by the Commission, Insurance Commissioner, private carrier or
self-insured employer, whichever is applicable, for good cause shown, file with
the office of judges his written objections, specifying the particular
statements of the Board's findings and conclusions to which the party
objects. Upon receipt of such
objection, the office of judges shall set a time and place for a hearing
thereon and shall notify each interested party and each member of the Board of
the time and place of the hearing.
52.7. Hearings on
protest.
Hearings held upon protest to the findings of the Occupational
Pneumoconiosis Board will be held by the office of judges in Charleston unless
the office of judges shall otherwise direct.
The procedure in protest hearings shall be governed by the provisions of
the procedural rules of the office of judges, except that evidence shall be
limited to medical testimony and other competent medical evidence, unless the
Board has passed upon non-medical aspects under the Commission's or Insurance
Commissioner’s, whichever is applicable, referral. Cross-examination of the Board shall be limited to those members
who examined the injured worker.
However, if the office of judges decides that testimony of other members
of the Board is necessary or desirable, the office of judges may permit such
testimony at the protest hearing.
52.8. Employer's
Request For Medical Examination.
An employer's request for medical examination of the injured
worker by a physician of its choice, shall be rejected if filed before the
findings of the Occupational Pneumoconiosis Board have been transmitted to the
injured worker and the employer. Such
requests shall be entertained only when filed subsequent to the transmittal of
the Occupational Pneumoconiosis Board findings.
52.9. Standards for
medical examination.
a. The following
standards specify examination and evaluation criteria to guide the Occupational
Pneumoconiosis Board in its examination and evaluation of injured workers, and
to guide other physicians and medical technicians who conduct examinations and
evaluations of injured workers on behalf of such injured workers and their
employers. These standards are
established for the further purpose of ensuring that uniform procedures are
used in administering and interpreting ventilatory function tests and arterial
blood gas studies and that the best available medical evidence will be obtained
in support of a claim for occupational pneumoconiosis benefits. The physician supervising any such testing
and/or the technician administering any such testing will so indicate by
signing the reports. Any report of test
results submitted to the Occupational Pneumoconiosis Board must affirmatively
state, as to each of the standards individually, the fact that the particular
test or study was performed in compliance with that standard. In the event that any such report fails to
affirmatively show compliance with these standards, the Occupational
Pneumoconiosis Board may disregard all or any part of such test or study or
give such test or study such weight as the Board believes it deserves.
b. When two (2)
or more ventilatory function tests performed in reasonably close proximity in
time produce differing but acceptable results, the Commission or Insurance
Commissioner, whichever is applicable, at the request of the Occupational
Pneumoconiosis Board, may direct the parties to furnish additional evidence
and/or order additional testing at the laboratory utilized by the Occupational
Pneumoconiosis Board or other laboratories, all for the purpose of determining
whether any of the results are unreliable or incorrect or are clearly
attributable to some identifiable disease or illness other than occupational
pneumoconiosis.
c. When blood gas
studies are performed and abnormal values are obtained and thereafter new blood
gas studies are performed and normal or significantly higher values are further
obtained, the Commission or Insurance commissioner, whichever is applicable, at
the request of the Occupational Pneumoconiosis Board, may direct the parties to
furnish additional evidence and/or order additional studies at the laboratory
utilized by the Occupational Pneumoconiosis Board or other laboratories, all
for the purpose of determining whether any of the values are unreliable or incorrect
or are clearly attributable to some identifiable disease or illness other than
occupational pneumoconiosis.
d. As used
herein, the following terms shall have the meanings indicated:
1. FVC
-forced vital capacity -- Volume of air
that can be forcefully exhaled from the lungs after a maximal inspiration.
2. FEV1
-forced expiratory volume in one (1) second --
Volume of air that can be exhaled forcefully from the lungs in one (1)
second after a maximal inspiration.
3.. FEV3
-forced expiratory volume in three seconds --
Volume of air that can be exhaled forcefully from the lungs in three (3)
seconds after a maximal inspiration.
4. FEV1FEV
-forced expiratory volume (timed) to forced expiratory volume. -- A
ratio expressed as a percentage.
5. MVV
-maximal voluntary ventilation -- The
volume of air that can be exchanged over a unit period of time, usually
performed for twelve (12) to fifteen (15) seconds and converted to liters per
minute.
6. BTPS
-- Body temperature, ambient pressure,
saturated with water.
7. Kpm
-kilopond meter -- The amount of work
required to lift one (1) kilogram one (1) meter.
8. NIOSH
-- National Institute for Occupational
Safety and Health.
9. BOARD
-- West Virginia Occupational
Pneumoconiosis Board.
10. NBRC –
National Board for Respiratory Care
11. CPFT –
Certified Pulmonary Function Technician
12.
RPFT -- registered Pulmonary Function technologist
13. Raw –
Airway resistance
14. DLCO –
Carbon monoxide diffusing capacity of the lungs
15. DL/VA –
Carbon monoxide diffusing capacity per unit of alveolar volume
16. VA –
Alveolar volume (single breath equivalent to TLC)
17. TLC –
Total Lung Capacity (measured by plethysmograph, Nitrogen washout, or helium
dilution.
e. Ventilatory
function tests.
1.
Instruments to be used for the administration of ventilatory function
tests should conform to the following criteria:
A.
The instrument must be accurate within plus (+) fifty (50) ml or within
plus (+) three percent (3%) of reading, whichever is greater.
B.
The instrument must be capable of measuring vital capacity from zero (0)
to seven (7) liters BTPS.
C.
The instrument must have a low inertia and offer low resistance to
airflow such that the resistance to airflow at twelve (12) liters per second
must be less than 1.5 cm H20/liter/second.
D.
The zero time point for the purpose of timing the FEV1 must
be determined by extrapolating the steepest portion of volume-time curve back
to the maximal inspiration volume or by an equivalent method.
E.
Instruments incorporating measurements of airflow to determine volume
must conform to the same volume accuracy stated in Subdivision 52.9.e.1.A of
this regulation when present with flow rates from at least zero (0) to twelve
(12) liters per second.
F.
The instrument or user of the instrument must correct volumes to body
temperature saturated with water vapor (BTPS) under conditions of varying
ambient spirometer temperatures and barometric pressures.
G.
The instrument used must provide tracings of volume versus time during
the entire forced expiration. Flow
versus volume tracings may be added. If
MVV maneuver is performed, the volume versus time tracings must also be
provided. Such tracing must be
furnished to the Board with the test results.
Volume Scale: When a volume – time curve is plotted or displayed, the
volume scale must be at least: 10 mm/L (BTPS).
Time scale: at least 10 mm/S. No
results will be considered by the Board unless they are accompanied by the
corresponding (minimum 3) tracings.
Tracings are to determine whether the subject has performed the test
properly. The tracing must be of
sufficient size that hand measurements may be made within the requirement of
paragraph 1A above.
H.
The instrument must be capable of accumulating volume for a minimum of
ten (10) seconds after the onset of exhalation.
I.
The forced expiratory volume in one (1) second (FEV1
measurement must comply with the accuracy requirements stated in Subdivision
52.9.e.1 of these Regulations; that is, the FEV1 must be accurately
measured to within plus (+) fifty (50) ml or within plus (+) three percent (3%)
of reading, whichever is greater.
J.
The instrument must be capable of being calibrated in the field with
respect to the FVC and time scales.
This calibration of the FVC may be done either directly or indirectly
through volume and time base measurements.
The volume calibration source must provide a volume displacement of at
least three (3) liters and must be accurate to within plus (+) thirty (30) ml.
K.
For measuring maximum voluntary ventilation (MVV), the instrument must
have a response which is flat within plus (+) ten percent (10%) at flow rates up
to twelve (12) liters per second over the volume range. The time for exhaled volume integration or
recording must be no less than twelve (12) seconds and no more than fifteen
(15) seconds. The indicated time must
be accurate to within plus (+) three percent (3%). A recording of the spirometer tracing is required, and the volume
sensitivity must be such than ten (10) mm or more deflection corresponds to one
(1) liter volume.
2. The
administration of ventilatory function tests must conform to the following
criteria: For ascertainment of the FEV1 and FVC, a nose clip or
alternative must be used. The
procedures must be explained in simple terms to the subject who shall be
instructed to loosen any tight clothing and sit or stand in front of the
apparatus. Although the subject may sit
or stand, care should be taken on repeat testing that the same position is
used. Sitting position will be
considered the preferred method although standing may be utilized for obese
patients and notations made as to the position. Particular attention must be given to insure that the subject's
chin is slightly elevated with the neck slightly extended. The subject must be instructed to make a full
inspiration, either from the spirometer or the open atmosphere, and then blow
into the apparatus, without interruption, as hard, fast, and completely as
possible.
At least three (3) forced expirations must be
carried out. During the maneuvers, the
subject must be observed for compliance with instructions. The expirations must be checked visually for
reproducibility by examining the flow-volume or volume-time tracings. The effort shall be judged unacceptable and
cannot be considered in evaluating pulmonary functional impairment when the
subject:
A.
The largest and second largest FVC are not within 7% of each other; or
B.
The largest and second largest FEV1 are not within 7% of each
other; or
C.
Has not continued the expiration for at least six (6) seconds or until
an obvious plateau in the volume-time curve has occurred. Exceptions: Young adults and patients with
restrictive defects tend to plateau early.
Reduced FVC with a normal or high FEV1/FVC ration is
suggestive of restriction, although measurement of TLC is required to confirm
restriction; or
D. Tracings indicate cough prior to the FEV1 measurement;
or
E.
Early termination of flow (glottis closure); or
F.
Has an unsatisfactory start of expiration, one characterized by
excessive hesitation (or false starts), and therefore did not allow back
extrapolation of time zero (0) (extrapolated volume on the volume-time tracing
must be less than ten percent (10%) of the FVC); or
G.
Has an excessive variability between the three (3) acceptable
curves. The variation between the two
(2) largest FVCs and the two (2) largest FEV1s.
H.
Predicted values are derived from Kory's Nomogram (1961).
3. For
ascertainment of the MVV, the subject must be instructed before beginning the
test that he or she will be asked to breathe as deeply and as rapidly as
possible for approximately twelve (12) seconds. Sitting position will be considered the preferred method although
standing may be utilized for obese patients and notations made as to the
position. Care shall be taken on
repeated testing that the same position is used. The test may be performed with the subject in either a sitting or
standing position. Care shall be taken
on repeat testing that the same position is used. The subject should breathe normally into the mouthpiece of the
apparatus for ten (10) to fifteen (15) seconds to become accustomed to the
system. The subject should then be
instructed to breathe as deeply and as rapidly as possible and shall be
continually encouraged during the remainder of the maneuver. The subject shall continue the maneuver for
twelve (12) seconds. Only one (1) MVV maneuver is necessary. The effort must be judged unacceptable and
cannot be considered in evaluating pulmonary functional impairment when the
patient:
A.
Has not maintained consistent effort for at least twelve (12) to fifteen
(15) seconds; or
B.
Has coughed or closed his glottis; or
C.
Has an obstructed mouthpiece or a leak around the mouthpiece
(obstruction due to tongue being placed in front of mouthpiece, false teeth
falling in front of mouthpiece, etc.); or
D.
Has an excessive variability between the three (3) satisfactory
curves. The variation between the three
(3) satisfactory tracings must not exceed ten percent (10%) and should
approximate forty (40) times the greatest FEV1 volume.
4. A
calibration check must be performed on the instrument each day before use,
using a volume source of at least three (3) liters, accurate to within +one
percent (1%) of full scale. The room
air in the syringe must be introduced into the spirometer once with a flow rate
of approximately five tenths (5/10) liters per second (six (6) seconds emptying
time with a three (3) liter syringe) and once with a higher flow rate of
approximately three (3) liters per second (one (1) second emptying time with a
three (3) liter syringe). The volume
measured by the spirometer must be between two and nine tenths (2.90) and three
and one tenth (3.10) liters for both trials.
Accuracy of the time measurement used in determining the FEV1 must
be checked using the manufacturer's stated procedure and must be within +three
percent (3%) of actual. The procedure
described herein must be performed as well as any other procedures suggested by
the manufacturer of the spirometer being used.
5. The first
step in evaluating a spirogram for the FVC and FEV1 shall be to
determine whether or not the subject has performed the test properly or as
described in Subdivision 52.9.e.2 of this regulation and the forced expiratory
volume. From the three (3) satisfactory
tracings, the forced vital capacity (FVC) and the forced expiratory volume in
one (1) second (FEV1) must be measured and recorded. The largest FVC and the largest FEV1
must be used in the analysis, corrected to BTPS.
6. Only MVV
maneuvers which demonstrate consistent effort for at least twelve (12) seconds
shall be considered acceptable. The
largest accumulated volume for a twelve (12) second period corrected to BTPS
and multiplied by five (5) shall be reported as the MVV.
f. Single Breath Carbon
Monoxide Diffusion Capacity
1. For
ascertainment of the Single Breath DLCO, the subject must be instructed before
beginning the test that he or she will be asked to breath normally through the
system for a number of breaths to achieve stable tidal breathing, then exhale
to the level of residual volume (RV).
At that point, the patient will be instructed to inhale quickly to the
level of Total Lung Capacity (TLC) and hold their breath for approximately 10 seconds,
then exhale for sample collection in the instruction of the technician
administering the test.
2. Single
breath carbon monoxide diffusion capacity tests are performed using the
Jones-Meade method of measurement.
3.
Predicted values are derived from Crapo (1981) nomogram.
4. Total
Hemoglobin and Carboxyhemoglobin are to be reported. Subjects with anemia will have results corrected to hemoglobin of
14.6 (males) and 13.4 (females).
5. IVCs
from each acceptable maneuver shall be reported.
6. Reports
will include DLCO, Alveolar Volume (VA) and DL/VA.
7. At least
two (2) maneuvers are to be carried out.
During the maneuvers, the subject must be observed for compliance of
instructions. The effort(s) shall be
judged unacceptable and cannot be considered in evaluating pulmonary function
impairment when the subject:
A.
IVCs do not achieve 85% of previously measured vital capacity.
B.
Actual DLCO measurements are not within 3 ml or 10% whichever is larger.
C.
IVCx (SVCs) are not reported for each acceptable maneuver.
D.
Inspiratory time exceeds 2.5 seconds.
E.
Breath hold time is less than 9 seconds or exceeds 11 seconds.
F.
Sample is not obtained within 4 seconds after breath hold.
G.
Carboxyhemoglobin is not reported or value is 3.1% or higher.
g. AIRWAY
RESISTANCE (Raw)
1. Airway
resistance measurement will be measured using a body plethysmograph. For ascertainment of the Raw, the subject
must be instructed before beginning the test that he or she will, after being sealed
in the plethysmograph, be asked to breath normally while temperature
equilibration occurs and then to hold cheeks with hands and gently pant while
open and close shutter measurements are taken.
h. Arterial blood
gas studies.
1. In order
to ensure comparability of data obtained in arterial blood studies, the
following guidelines should be observed:
A.
The puncture site should be infiltrated with a local anesthetic to
minimize pain and arterial spasm.
B.
The barrel of the syringe used to draw the blood sample should contain a
coating of lithium heparin. If wetted
syringes are used, the excess heparin must be expelled just prior to obtaining
the blood sample.
C.
The subject should be allowed to rest while breathing room air for
fifteen (15) minutes prior to drawing the sample.
D.
Resting blood samples should be drawn with the subject in the sitting
position. If supine position is
necessary, a notation is to be made on the report.
E. On
occasions when the subject is unable to be exercised due to physical
impairments; i.e., heart disease, artificial leg, etc., a resting sample of
arterial blood may be drawn by direct puncture with a twenty-twenty-five
(20-25) gauge needle and a heparinized syringe.
F.
Blood samples must be discarded if contaminated by an air bubble.
G.
All blood samples should be analyzed immediately (less than ten (10)
minutes). If not, the sample should be
placed in ice water slush for up to 1 hour.
If the analysis is not performed within ten (10) minutes, the metabolic
activity of the cells in the blood will cause the p02 to fall and
the pC02 to rise.
H. If
an exercise sample is to be obtained, a plastic catheter may be inserted into
the radial or brachial artery for both the resting as well as the exercise
sample. Single stick exercise samples
may also be obtained if drawn during the last 30 seconds of exercise. Any variation should be so noted.
I.
Exercise must be accomplished by having the subject pedal the bicycle
ergometer at a rate of fifty (50)-sixty (60) revolutions per minute against a
resistance of seventy-five (75) Watts or four hundred fifty (450) Kilopond
Meters (Kpm) per minute for a period of five (5) minutes. A treadmill may be used, and when used,
exercise must be done at two (2) mph and ten percent (10%) grade. During the last twenty (20) seconds of the
fifth minute of exercise, the exercise sample must be drawn into a heparinized
syringe and the pulse and respiration rates noted. If an added level of exercise is performed, this must be done at
one hundred twenty (120) Watts on the bicycle, or on the treadmill at two and
five tenths (2 5/10) mph and twelve percent (12%) grade. Exercise testing beyond the level set forth
herein shall be considered to be measurements of physical conditioning rather
than of blood gas transfer abnormalities due to occupational
pneumoconiosis. The EKG leads are then
removed and the subject allowed to sit on a chair while the catheter is
removed. Pressure must be held at the site
of arterial cannulation for five (5) minutes, and if there is no bleeding or
hematoma present, a compression bandage must be placed on the radial
artery. This bandage must be left in
place for four (4) hours. After about
fifteen (15) minutes of observation, the subject will be allowed to leave. The arterial blood sample should be drawn
while exercise continues, not following cessation of exercise.
J.
EKG monitoring with a single lead should take place during exercise to
determine the heart rate. It should be
noted that this is not an EKG Stress Test.
K.
The report should indicate the place, date and time of the study,
altitude of the testing site and barometric pressure at the testing site on the
day of the testing, name and claim number of the subject, name of any assisting
personnel, name and signature of the supervising physician, duration and type
of exercise (if performed), pulse rate and respiration at the time the blood
sample was drawn, and whether analysis equipment was calibrated before each
test.
2. It is
recognized that arterial blood gas studies done in laboratories throughout this
state are obtained at different altitudes.
Only by "Standardizing" for altitude can an equitable
assessment be made of impairment when values of arterial oxygen are being
measured at remarkably different altitudes.
Therefore, the results reported from laboratories should include the
name of the laboratory and the date and time of the testing, altitude of the
laboratory and barometric pressure at the laboratory on the day the samples
were collected. The Occupational
Pneumoconiosis Board will evaluate the arterial blood gas values by converting
those values to the average altitude of Charleston, West Virginia. For this purpose, it shall be sufficient to
add one (1) mmHg to each arterial oxygen tension for each three hundred (300)
feet or fraction thereof that the testing laboratory is located above the
average altitude of Charleston, because the relationship of barometric pressure
(altitude) and alveolar oxygen is approximately linear up to four thousand
(4,000) feet as long as the subject breathes room air.
As an example, Bluefield is located approximately
two thousand six hundred (2,600) feet above sea level. Charleston is approximately six hundred
(600) feet above sea level. Thus,
arterial oxygen values obtained in Bluefield should have 6.67 mmHg added to
them before applying the table to them to obtain "percent
impairment". The calculations are
as follows:
"Bluefield (2,600') minus Charleston (600')
equals 2,000' differential
2,000' divided by 300' altitude equals 6.67
6.67 multiplied by 1 mmHg per 300' altitude equals
6.67 mmHg"
i. See the
attached Table 85-20A, “Impairment of Pulmonary Function.”
52.10. Treatment Issues
The following services may be provided without prior
authorization if carried out under the standards referenced and if the service
is documented as to its medical necessity.
1. MEDICAL VISITS: Office visits will be considered for payment according to the following schedule based on the FEV1/FVC ratio or upon percent of disability award (where there is a conflict, FEV1 will be the controlling factor):
|
FEV1/FVC* |
WCF % OP AWARD |
LEVEL OF IMPAIRMENT |
MEDICAL VISITS |
|
70-74% |
10-15% |
I |
One intermediate visit per
year. |
|
61-69% |
20-30% |
II |
One comprehensive or
extended visit per year for medically necessary pulmonary follow-up care. |
|
60% or less |
40%> |
III |
One comprehensive or
extended visit per year. Up to four
limited visits per year for medically necessary pulmonary follow-up care. |
*Based on Actual Results
rather than Nomograms.
2. TESTING: The testing referenced below will only be
considered for payment when the medical necessity is documented by the treating
physician. Equivalent testing performed
in conjunction with the claimant’s examination by the OP board shall be
considered toward satisfaction of the limits herein referenced. This testing, with the exception of chest
X-rays, is not applicable to claimants with Zero Level of Impairment.
a)
Spirometry: Annually in
conjunction with a comprehensive, extended or intermediate office visit. This testing must be performed in compliance
with the standards outlined in the Commission’s or Insurance Commissioner’s,
whichever is applicable, rules and regulations.
b) Single
Breath Diffusion Study: Once for all
eligible claimants. Repeat every two
years if less than 60% of predicted.
Repeat every four years if 60% of predicted or greater.
c) Chest
X-Ray: Normal – every four years maximum. Positive reading for OP -- every two years maximum.
d) Blood
Tests: Theophylline level annually for
claimants taking theophylline medication.
Additional theophylline testing will be considered when necessary to
monitor and stabilize the blood levels during the first year of ingestion.
Complete blood count and Chemistry – 12 every four
years for claimants in Level II.
Complete blood count and Chemistry – 12 annually
for claimants in Level III.
This testing is not authorized for claimants in
Levels 0 and I.
3.
MEDICATIONS: The following will
be considered for payment prescribed for an acute or chronic condition or
problem caused or exacerbated by OP and when such has been documented by the
treating physician.
All above 15% PPD
a) Bronchodilators for claimants with a 15% or
greater improvement in FEV1 or FVC on a current post bronchodilator
study.
b) Other
medications on the Medicaid formulary including antibiotics, steroids and
diuretics when required for treatment of pulmonary conditions related to OP for
up to 14 days of treatment. Longer
treatment may be authorized but will require prior authorization based upon a
statement of medical necessity from the treating physician and appropriate
prescribing practices.
c) Expectorants or mucolytics will not be approved.
d)
Pneumococcal vaccine once and annual flu vaccine for all eligible
claimants where the physician certifies that the vaccine is consistent with
national guidelines of immunization practices regarding health status and age
of the patient.
e) Cardiac
medications may be authorized when the cardiac problem is a complication of the
pneumoconiosis. Authorization will not
be granted for treatment of cardiac conditions unrelated to occupational
pneumoconiosis, nor for cardiomyopathy, coronary heart disease or coronary
bypass surgery.
4. PULMONARY
REHABILITATION: Pulmonary
rehabilitation services are authorized according to the following schedule when
such services are provided by a certified pulmonary rehabilitation center
approved by the U. S. Department of Labor and provided in accordance with the
guidelines of the WV Department of Health.
|
LEVEL OF IMPAIRMENT |
WCF % AWARD |
FEV1/FVC* |
AUTHORIZED TREATMENT |
|
A |
5% |
75% or greater |
None |
|
B |
10-15% |
70-74% |
One hour of education
focusing on the nature of pulmonary disease and prevention of progression. |
|
C |
20-40% |
56-69% |
Additional four hours of
education and training focusing on techniques and dealing with shortness of
breath and pulmonary distress management. (5 hours total) Two
hours of follow-up education and training one year later. |
|
D |
40%> |
55% or less |
Additional two hours of
education training focusing on individualized treatment of severe pulmonary
impairment. (7 hours total) Two hours of follow-up education and
training one year later. |
|
Homebound claimants (as
result of pulmonary impairment) |
Seven hours of education
and training by home visitation. Two hours of follow-up
education and training each subsequent year. |
||
Pulmonary rehabilitation programs
coverage includes: Prevention of
disease progression, nutrition, hygiene, anatomy, recognition of symptoms,
smoking cessation, physical conditional, weight control, breathing techniques,
drug evaluation, stress reduction and follow-up.
Pulmonary rehabilitation services
must be provided by a registered nurse, licensed practical nurse or respiratory
therapist.
The following services require prior
authorization and the request for such authorization must be accompanied by a
statement of medical necessity from the treating physician.
1.
Arterial Blood Gas (Or Oximetry):
a) Administration of arterial blood gases or
oximetry shall be restricted to situations where it is necessary to evaluate
the need for chronic oxygen therapy consistent with American Thoracic Society
Guidelines.
b) Prior authorization is also required to
repeat blood gases and is contingent upon the treating physician providing
documentation that the claimant’s initial study showed a PO2 over 80
or 02 saturation over 95%. The PO2
levels listed below will be the determining factor in how frequently the repeat
test will be considered for authorization.
PO2
less than 55 or O2 less than 90% saturation – repeat no more than
annually.
PO2
55 to 80 or O2 saturation 90 to 95% - repeat no more than every two
years.
PO2
over 80 or O2 saturation over 95% - repeat no more than every four
years.
2.
Durable medical equipment and nursing care:
a) Purchase or rental of durable equipment such
as hospital beds, commode chairs and lifts.
Authorization of durable medical equipment, including oxygen delivery
systems, shall be given in the sole discretion of the Commission, Insurance
Commissioner, private carrier or self-insured employer, whichever is
applicable.
b) In-home nursing care or home health care for
bedridden claimants.
c) Nursing home care in properly licensed and
operated facilities.
d) Mechanical nebulizer: Authorization for Mechanical nebulizers
shall only be granted upon certification of medical necessity from the treating
physician which indicated why the use of less expensive medication delivery
such as hand nebulizers or metered dose devices is not feasible.
3.
Oxygen: Except when administered
for medical emergency, oxygen therapy requires prior authorization and will
only then be authorized when in compliance with the guidelines of the American
Thoracic Society.
§85-20-53. Long-Term Opioid
Therapy Guideline.
53.1. These guidelines are used by the provider in the management of
chronic nonmalignant pain. Chronic
nonmalignant pain is defined as pain persisting beyond the expected normal
healing time for an injury, for which traditional medical approaches have been
unsuccessful. These guidelines do not apply to claimants whose pain is the
result of a malignant process (cancer), or when the pain therapy is aimed at
relieving intractable pain and suffering in the terminally ill when other
measures fail, assuming a compensable diagnosis.
53.2. Successful management of intractable chronic non-malignant pain
(hereinafter referred to as “chronic pain”) usually does not require the use of
opioid medications. There are other effective and non-pharmacologic treatment
interventions available. Some carefully selected claimants with chronic pain
may benefit from opioid maintenance analgesia (OMA). These claimants function
better, are sometimes able to resume working, maintain improved pain control
with acceptable side effects, and continue to use their medications in a
responsible manner.
53.3. In some claimants, long-term OMA fails. Pain control is marginal,
function does not improve, side effects prohibit ongoing therapy, or the
claimant’s ability to use the medication properly is poor or erratic. The key
to success in the management of OMA is careful selection of candidates and
monitoring.
53.4. Candidates for long
-- term OMA should:
a. Have an established diagnosis that is
consistent with chronic pain.
b. Have not responded to non-opioid treatment.
c. Not be pregnant. Claimants likely to become pregnant during the course of
treatment must be advised of the risks to the fetus should pregnancy occur.
d. Not be using illegal drugs or abusing
alcohol.
e. Be reliable claimants who are known to the
physician and are expected to be compliant with the treatment protocol.
53.5. Long term OMA is contraindicated for claimants who have
persistent pain out of proportion to physical findings and/or with no
demonstrable lesion, and who meet the criteria for the diagnosis of “chronic
pain syndrome”.
53.6. Documentation recommendations for controlled substances
prescribed within the guidelines.
a. A thorough medical history, physical
examination, diagnosis and treatment plan should be documented, with particular
attention focused on determining the cause(s) of the injured worker's pain,
sleeplessness or anxiety.
b. The treatment plan should include the
following information:
1. A list of all current medications (with
doses), including medications prescribed by other physicians (whenever
possible);
2. Therapies and procedures other than
medications to manage/relieve pain;
3. Consultations with health care
professionals;
4. Further planned diagnostic evaluation; and
5. Follow-up plan to assess progress.
c. The above standards for documentation are
being recommended for inclusion in the provider's records. These records should be submitted to the
Commission, Insurance Commissioner, private carrier or self-insured employer,
whichever is applicable.
53.7. Claimants with a personal history of addiction (or in their
immediate family) or poor impulse control are at an increased risk of failing
to comply with an OMA regimen.
The risk of abuse or adverse outcome
is high if any of the following factors are present:
a. History of active use of alcohol or other
substance abuse.
b. Co-morbid psychiatric disorders.
c. Poor response to opioids in the past for the
same condition.
53.8. All potential candidates for long-term OMA, with a positive
history of any of the above risk factors, must undergo a psychiatric or
psychological evaluation to determine the appropriateness of long-term OMA to
rule out co-morbid psychiatric disorders and the potential for addiction.
53.9. In addition, any claimant who has been on opioids without
evidence of improvement must also undergo a psychological evaluation.
53.10. The report of such an evaluation must be provided to the
claimant’s Workers’ Compensation Division Claims Manager as soon as possible
after starting the OMA.
53.11. There is no clinical indication for using injectable opioid
preparations for claimants with chronic pain.
Injectable opioid preparations should only be used in cases of acute
pain. They should never be prescribed
as a self-medication on an as needed basis.
53.12. Continuation of Long-Term OMA:
a. If low to moderate dose opioid therapy has
not provided at least partial analgesia, then long-term OMA is not indicated.
b. Complete analgesia is not the goal of
long-term OMA. The efficacy of the
therapy is measured not only by reduction in pain but also by improvement in
physical and social function.
Therefore, documentation of pain and function is essential to monitor
the success of the therapy. Functional
tool: Table 18.3 of the AMA Guides,
Fifth Edition, or a comparable tool.
c. Monitoring of the progress of the therapy
must be documented on the attached forms every 30 days the first three months
and every 60 days the next six months.
d. d. A
specialist experienced in pain management selected by the Commission, Insurance
Commissioner, private carrier or self-insured employer, whichever is
applicable, shall evaluate every claimant on long-term OMA annually to
determine the need for continuing OMA.
e. A treatment agreement between the patient
and the provider is recommended.
53.13. Definitions for this Section:
a. Acute pain is the normal, predicted
physiological response to an adverse chemical, thermal, or mechanical stimulus
and is associated with surgery, trauma, and acute illness. It is generally time-limited and is
responsive to opioid therapy among other therapies.
b. Chronic Non-malignant Pain is an evolving
pathological process that can be defined as pain persisting beyond the expected
reasonable healing time for an injury despite medical treatment.
c. Chronic Pain Syndrome (CPS): Any claimant presenting with persistent pain
of at least three months duration, which may be consistent with or
significantly out of proportion to physical findings, and who has at least two
of the four criteria listed below should be considered a CPS patient.
1. A progressive deterioration in ability to
function at home, socially, or at work.
2. A progressive increase in health care
utilization (such as repeated physical evaluations, diagnostic tests, requests
for pain medications, and/or invasive procedures).
3. Demonstrable mood disturbance.
4. Clinically significant anger.
d. Qualifications of the Pain Management
Specialist for evaluating and treating:
1. A pain management specialist must be
Board-certified by the American Board
of Medical Specialists. At this time,
the only such Board is the American Board of Anesthesiology and this board will
be available to all pain practitioners in the next year.
2. He/she must be licensed by the State of WV.
3. He/she should have at least three years
experience in chronic pain management, behavioral management, and/or addiction
4. The Commission, Insurance Commissioner,
private carrier or self-insured employer, whichever is applicable, will
annually provide a list of approved chronic opioid pain management specialists,
based on the above criteria and satisfactory objective measures of prior
performance.
e. Qualifications of the Psychologist for evaluating and treating:
1. The psychologist must be licensed by the
State of WV.
2. He/she should have at least three years
experience in chronic pain management, behavioral management, and/or addiction.
3. The Commission, Insurance Commissioner,
private carrier or self-insured employer, whichever is applicable, will
annually provide a list of approved chronic opioid pain evaluating
psychologists, based on the above criteria and satisfactory objective measures
of prior performance.
f. Qualifications of the Psychiatric Addiction
Specialist for evaluating and treating:
1. The psychiatrist must be licensed by the
State of WV.
2. He/she must be Board-certified in
Psychiatry.
3. He should have at least three years experience
in treating patients with addictive disorders and have active hospital
privileges in the treatment of same.
4. The Commission, Insurance Commissioner,
private carrier or self-insured employer, whichever is applicable, will
annually provide a list of approved psychiatric addictive specialists, based on
the above criteria and satisfactory objective measures of prior performance.
53.14. Guidelines for the prescription for controlled substances
schedules II - IV (refer to Table § 85-20-B for controlled substances schedule)
a. Schedule II drugs should be prescribed on an
outpatient basis for no longer than two weeks after initial injury or following
a subsequent operative procedure.
b. Schedule III drugs should be prescribed on
an outpatient basis for no longer than six weeks after initial injury or
following a subsequent operative procedure.
c. Schedule IV opioid drugs should be
prescribed on an outpatient basis for no longer than six weeks after initial
injury or following a subsequent operative basis.
d. Schedule IV sedative and anxiolytic drugs
should be prescribed on an outpatient basis for no longer than six months after
initial injury or following a subsequent operative procedure.
e. To prescribe medications beyond the above
guidelines, authorization must be obtained from the Commission, Insurance
Commissioner, private carrier or self-insured employer, whichever is
applicable. Authorization requests must
include documentation as described in the Rule. It is recommended that providers utilize less potent medications
when continued use is indicated.
53.15. The Commission, Insurance Commissioner, private carrier or
self-insured employer, whichever is applicable, will not reimburse for
treatment in methadone maintenance programs.
These programs are specifically intended to manage opiate addiction and
the Commission, Insurance Commissioner, private carrier or self-insured
employer, whichever is applicable, shall not reimburse costs of treatment,
medication, or any other expense associated with these programs.
V. SPECIAL RULES ON DRUGS AND MEDICATIONS
§85-20-54. Drugs with Specific Limitations.
54.1. Injectables. Prescriptions for injectable opioids or other
analgesics, sedatives, antihistamines, tranquilizers, psychotropics, vitamins,
minerals, food supplements, and hormones are not covered.
54.2. Exceptions: The Commission, Insurance Commissioner, private
carrier or self-insured employer, whichever is applicable, covers injectable
medications under the following circumstances.
a. Indicated injectable drugs for the
following:
1. Inpatients; or
2. During emergency treatment of a
life-threatening condition/injury; or
3. During outpatient treatment of severe soft
tissue injuries, burns or fractures when needed for dressing or cast changes;
or
4. During the perioperative period and the
postoperative period, not to exceed forty-eight hours from the time of
discharge.
b.
Prescriptions of injectable insulin, heparin and related anticoagulants,
anti-migraine medications, or impotency treatment, when proper and necessary.
54.3. Noninjectable
scheduled drugs administered by other than the oral route. Nonoral routes of
administration of scheduled drugs that result in systemic availability of the
drug equivalent to injectable routes will also not be covered.
54.4.
Sedative-hypnotics. During the chronic stage of an industrial injury or
occupational disease, payment for scheduled sedatives and hypnotics will not be
authorized.
54.5. Benzodiazepines.
Payment for prescriptions for benzodiazepines is limited to the following types
of patients:
a. Hospitalized
patients;
b. Injured
workers with an accepted psychiatric disorder for which benzodiazepines are
indicated;
c. Injured
workers with an unrelated psychiatric disorder that is retarding recovery but
which the Commission, Insurance Commissioner, private carrier or self-insured
employer, whichever is applicable, has temporarily authorized treatment and for
which benzodiazepines are indicated; and
d. Other
outpatients for not more than thirty days for the life of the claim.
54.6. Cancer. When
cancer or any other end-stage disease is an accepted compensable condition, the
department or self-insurer may authorize payment for any indicated scheduled
drug and by any indicated route of administration.
54.7. Spinal cord
injuries. When a spinal cord injury is an accepted condition, the Commission,
Insurance Commissioner, private carrier or self-insured employer, whichever is
applicable, may authorize payment for
anti-spasticity medications by any indicated route of administration (e.g.,
some benzodiazepines, Baclofen). Prior authorization is required.
§85-20-55. Drugs and
Medications: Actions.
55.1. The Commission, Insurance Commissioner,
private carrier or self-insured employer, whichever is applicable, may take any
or all of the following steps when concerned about the amount or
appropriateness of drugs the patient is receiving:
a. Notify the
attending physician of concerns regarding the medications such as drug
interactions, adverse reactions, prescriptions by other providers;
b. Require that
the attending physician send a treatment plan addressing the drug concerns;
c. Request a
consultation from an appropriate specialist;
d. Request that
the attending physician consider reducing the prescription, and provide
information on chemical dependency programs;
e. Limit payment
for drugs on a claim to one prescribing doctor.
55.2. If the attending
physician or worker does not comply with these requests, or if the probability
of imminent harm to the worker is high, the Commission, Insurance Commissioner,
private carrier or self-insured employer, whichever is applicable, may
discontinue payment for the drug after adequate prior notification has been
given to the worker, pharmacy and physician.
55.3. Physician failure
to reduce or terminate prescription of controlled substances, habit forming or
addicting medications, or dependency inducing medications, after the Commission,
Insurance Commissioner, private carrier or self-insured employer, whichever is
applicable, request to do so for an injured worker may result in a transfer of
the worker to another physician of the worker's choice
§85-20-56. Physician’s Records of
Medication.
The physician's record must
contain the name and reason for the medication, the dosage, quantity prescribed
and/or dispensed, the route of administration, the frequency, the starting and
stopping dates, the expected outcome of treatment, and any adverse effects that
occur. Failure to maintain these
records may be considered abuse under W. Va. Code §23-4-3c.
§85-20-57. Payment for oral
opioid treatment for chronic, noncancer pain.
Chronic, noncancer pain may
develop after an acute injury episode. It is defined as pain that typically
persists beyond two to four months following the injury. The Commission, Insurance Commissioner,
private carrier or self-insured employer, whichever is applicable, in its sole
discretion, may pay for oral opioids for the treatment of chronic, noncancer
pain caused by an accepted condition when that treatment is reasonably
required.
§85-20-58. Required
authorization for treatment of chronic, noncancer pain with opioids.
58.1. No later than thirty days after the
attending physician begins treating the worker with opioids for chronic,
noncancer pain, the attending physician must submit a written report to the
Commission, Insurance Commissioner, private carrier or self-insured employer,
whichever is applicable, in order for the Commission, Insurance Commissioner,
private carrier or self-insured employer, whichever is applicable, to pay for
such treatment. The written report must include the following:
a. A treatment
plan with time-limited goals, including a time schedule to wean the injured
worker from opiod use;
b. A
consideration of relevant prior medical history;
c. A summary of
conservative care rendered to the worker that focused on reactivation and
return to work;
d. A statement on
why prior or alternative conservative measures may have failed or are not
appropriate as sole treatment;
e. A summary of
any consultations that have been obtained, particularly those that have
addressed factors that may be barriers to recovery;
f. A statement
that the attending physician has conducted appropriate screening for factors
that may significantly increase the risk of abuse or adverse outcomes (e.g., a
history of alcohol or other substance abuse); and
g. An opioid
treatment agreement that has been signed by the worker and the attending
physician. This agreement must be renewed every six months. The treatment
agreement must outline the risks and benefits of opioid use, the conditions
under which opioids will be prescribed, the physician's need to document
overall improvement in pain and function, and the worker's responsibilities.
§85-20-59. Required
documentation to be submitted for continued coverage of opioids to treat
chronic, noncancer pain.
59.1. In addition to the general documentation
required by the Commission, Insurance Commissioner, private carrier or
self-insured employer, whichever is applicable, the attending physician must
submit the following information at least every sixty days when treating with
opioids:
a. Documentation
of drug screenings, consultations, and all other treatment trials;
b. Documentation
of outcomes and responses, including pain intensity and functional levels; and
c. Any
modifications to the treatment plan.
The physician must document the patient's improvement in
pain intensity and functional levels.
§85-20-60. Duration of payment
for opioids to treat chronic, noncancer pain.
60.1. The Commission, Insurance Commissioner,
private carrier or self-insured employer, whichever is applicable, will
continue to pay for treatment with opioids if directly related to a compensable
condition so long as the physician documents in addition to the information
required in Section 58 of this Rule:
a. Substantial
reduction of the patient's pain intensity; and
b. Continuing
substantial improvement in the patient's function. Once the worker's condition has reached maximum medical
improvement, further treatment with opioids is not payable. Opioid treatment
for chronic, noncancer pain past the first three months of such treatment
without documentation of substantial and progressive continuing improvement is
presumed to be not proper and necessary.
§85-20-61. Denial of payment of
opioid medications used to treat chronic, noncancer pain.
61.1. Payment for opioid medications may be denied
in any of the following circumstances:
• Absent or
inadequate documentation;
• Noncompliance
with the treatment plan;
• Pain and
functional status have not substantially improved after three months of opioid
treatment; or
• Evidence of
misuse or abuse of the opioid medication or other drugs, or noncompliance with
the attending physician's request for a drug screen.
§85-20-62. Payment for
nonopioid medications for the treatment of chronic, noncancer pain; Chelation
therapy.
62.1. The Commission, Insurance Commissioner,
private carrier or self-insured employer, whichever is applicable, may pay for
nonopioid medication for the treatment of chronic, noncancer pain when it is
proper and necessary and directly related to a compensable injury. For example, some drugs such as
anti-convulsants, anti-depressants, and others have been demonstrated to be
useful in the treatment of chronic pain and may be approved when proper and
necessary.
62.2. All chelation
therapy (oral and IV) requires prior authorization and consultation with a
Board Certified Medical Toxicologist, an occupational medicine specialist, or
general internist familiar with principals of toxicology, prior to initiation
of the therapy. In the rare incident,
in which acute encephalopathy occurs as the result of heavy metal toxicity, a
consultation with the Poison Control Center will serve as confirmation of the
need for such chelation therapy. The Commission,
Insurance Commissioner, private carrier or self-insured employer, whichever is
applicable, will not reimburse for IV chelation therapy performed in
office.
VI. EXPECTED PERIOD OF TIME TO
REACH MAXIMUM MEDICAL IMPROVEMENT
§85-20-63. Expected period of
time to reach maximum medical improvement.
Pursuant to W. Va. Code
§23-4-3b(b), the Commission or Insurance Commissioner, whichever is applicable,
hereby incorporates by reference the Medical Disability Advisor, Workplace
Guidelines for Disability Duration, Presley Reed, MD (4th Edition)
(“Presley Reed Guide”) for purposes of establishing the expected period of time
to reach maximum medical improvement and for continued treatment for various
injuries and diseases. The
requirements, standards, parameters and limitations of the Presley Reed Guide
shall have the same force and effect as this Rule. All requirements, standards, parameters and limitations of the
Presley Reed Guide are hereby deemed medically reasonable and any requirements,
standards, parameters and limitations which exceed those set forth in the
Presley Reed Guide are hereby deemed medically unreasonable. A preponderance of evidence, including but
not limited to, detailed and documented medical findings, peer reviewed medical
studies, and the elimination of causes not directly related to a compensable
injury or disease, must be presented to
establish that requirements, standards, parameters and limitations in excess of
those provided for in the Presley Reed Guide are medically reasonable.
Nothing in this rule shall prohibit employers, private carriers
or self-insured employers, whichever is applicable, from using other guidelines for the purpose of establishing the
expected period of time and medical treatment protocols necessary to reach
maximum medical improvement for various injuries and diseases, as long as such
guidelines are part of a managed care plan otherwise approved by the Commission
or Insurance commissioner, whichever is applicable, pursuant to W. Va. Code
§23-4-3(b)(2)(2003).
VII. RANGE OF PARTIAL DISABILITY
AWARDS FOR COMMON INJURIES AND DISEASES
§85-20-64. Ranges of partial
disability awards for common injuries and diseases.
64.1. Pursuant to W. Va. Code §23-4-3b(b), the
Commission or Insurance Commissioner, whichever is applicable, hereby adopts the
following ranges of permanent partial disability for common injuries and
diseases. Permanent partial disability
assessments shall be determined based upon the range of motion models contained
in the Guides Fourth. Once an
impairment level has been determined by range of motion assessment, that level
will be compared with the ranges set forth below. Permanent partial disability assessments in excess of the range
provided in the appropriate category as identified by the rating physician
shall be reduced to the within the ranges set forth below:
64.2. Lumbar Spine
Impairment: The range of motion
methodology for assessing permanent impairment shall be used. However, a single injury or cumulative
injuries that lead to a permanent impairment to the Lumbar Spine area of one’s
person shall cause an injured worker to be eligible to receive a permanent
partial disability award within the ranges identified in Table §85-20-C. The rating physician must identify the appropriate
impairment category and then assign an impairment within the appropriate range
designated for that category.
64.3. Thoracic Spine
Impairment: A single injury or cumulative injuries that lead to a permanent
impairment to the Thoracic Spine area of one’s person shall cause an injured
worker to be eligible to receive a permanent partial disability award within
the ranges identified in Table §85-20-D.
The rating physician must identify the appropriate impairment category
and then assign an impairment within the appropriate range designated for that
category.
64.4. Cervical Spine
Impairment: A single injury or cumulative injuries that lead to a permanent
impairment to the Thoracic Spine area of one’s person shall cause an injured
worker to be eligible to receive a permanent partial disability award within
the ranges identified in Table §85-20-E.
The rating physician must identify the appropriate impairment category
and then assign an impairment within the appropriate range designated for that
category.
64.5. Carpal Tunnel
Syndrome Impairment: An injured worker
who can otherwise show entitlement to a permanent partial disability award for
carpal tunnel syndrome shall be eligible to receive a permanent partial
disability award of 0%-6% in each affected hand.
64.6. Mental
Impairment: Psychiatric disability
ranges, along with all other ranges in this Rule, must be strictly adhered to
and ratings in excess of the ranges shall be considered evidence of abuse under
W. Va. Code §23-4-3c.
64.7. Arm: The statutory impairment for the amputation
of an injured worker’s arm is 60%.
Accordingly, a single or all cumulative injuries to an individual’s arm
shall not total more than 60%. As an
example, if an injured worker receives a 6% award for unilateral carpal tunnel,
a 30% award for a shoulder injury, and a 10% award for an elbow injury, he
shall not be entitled to any future award for injuries sustained to his
shoulder in excess of 14%. The
“bundling” of awards for injuries to the arm shall not exceed the 60%
amputation award.
64.8. Leg: The statutory impairment for the amputation
of an injured worker’s leg is 45%.
Accordingly, a single or all cumulative injuries to an individual’s leg
shall not total more than 45%. As an
example, if an injured worker is awarded a 20% award for a permanently impaired
hip and then is later awarded a 15% permanent impairment for an injury to his
knee, then he shall only be entitled to an additional 5% permanent award in
future injuries to his hip, thigh, knee, shin, ankle, foot, or any other part
of his leg. The “bundling” of awards for injuries to the leg shall not exceed
the 45% amputation award.
§85-20-65. Adoption of
Standards.
65.1. Except as
provided for in section 66 of this Rule, on and after the effective date of
this rule all evaluations, examinations, reports, and opinions with regard to
the degree of permanent whole body medical impairment which an injured worker
has suffered shall be conducted and composed in accordance with the “Guides to
the Evaluation of Permanent Impairment,” (4th ed. 1993), as
published by the American Medical Association. If in any particular claim, the
examiner is of the opinion that the Guides or the section 64 substitutes cannot
be appropriately applied or that an impairment guide established by a
recognized medical specialty group may be more appropriately applied, then the
examiner’s report must document and explain the basis for that opinion.
Deviations from the requirements of the Guides or the section 6 substitutes
shall not be the basis for excluding evidence from consideration. Rather, in
any such instance such deviations shall be considered in determining the weight
that will be given to that evidence. An example of an acceptable recognized
medical specialty group’s own guides is the “Orthopedic Surgeons Manual in
Evaluating Permanent Physical Impairment.”
65.2. These revised
rules are not applicable to any permanent impairment rating examination
performed prior to the effective date of these revised rules. Accordingly, the
revised rules are not applicable to any reports or opinions based upon those
examinations, in whole or in part, which are submitted either before or after
the effective date of these revised rules.
65.3. These rules are
applicable to examinations and opinions provided to the Commission, Insurance
Commissioner, private carrier or self-insured employer, whichever is
applicable, by an injured worker’s treating physician pursuant to W. Va. Code
§23-4-7a(c)(1).
§85-20-66. Evidentiary Requirements.
66.1. The evidentiary
weight to be given to a report will be determined by how well it demonstrates
that the evaluation and examination that it memorializes were conducted in
accordance with the applicable Guides and that the opinion with regard to the
degree of permanent whole body medical impairment suffered by an injured worker
was arrived at and composed in accordance with the requirements of the
applicable Guides.
66.2. The report must
state the factual findings of all tests, evaluations, and examinations that
were conducted and must state the manner in which they were conducted so as to
clearly indicate their performance in keeping with the requirements of the
Guides. For any evaluation and examination of a compensable back injury, the
back examination form previously adopted by the Workers’ Compensation
Commission must be completed and submitted with the narrative report. A copy of
the current edition of the back examination form can be obtained from the
Commission, Insurance Commissioner, private carrier or self-insured employer,
whichever is applicable. A report and
opinion submitted regarding the degree of permanent whole body medical
impairment as a result of a back injury without a completed back examination
form shall be disregarded.
66.3. The opinion
stated in the report as to the degree of permanent whole body medical
impairment must reflect the process of calculation as stated in the applicable
Guides so as to demonstrate how the degree of permanent whole body medical
impairment was arrived at and calculated.
66.4. To the extent
that factors other than the compensable injury may be affecting the injured
worker’s whole body medical impairment, the opinion stated in the report must,
to the extent medically possible, determine the contribution of those other
impairments whether resulting from an occupational or a nonoccupational injury,
disease, or any other cause.
66.5. In any claim for
occupational pneumoconiosis benefits, for noise induced hearing loss, or for
mental and emotional loss, the application of these evidentiary requirements of
this section shall be based upon the guidelines referred to below in lieu of
the Guides. All of the other requirements of this section shall be accordingly
applied.
§85-20-67. Exceptions to the
Guides.
The following portions of the applicable Guides or their
successor provisions shall not be used in the determination of the degree of
permanent impairment that has been suffered by an injured worker for workers’
compensation benefits.
67.1. In claims for
occupational pneumoconiosis benefits, the provisions of Chapter 5, “The
Respiratory System,” are exempted from this rule. The provisions of the statute
related to occupational pneumoconiosis, rules adopted in accordance with the
statute, and policies and procedures adopted by the occupational pneumoconiosis
board adequately and separately control the determination of the degree of
permanent impairment suffered by such an injured worker. The occupational
pneumoconiosis board may, in any given case and in its discretion, utilize the
Guides to the extent the board deems appropriate.
67.2. In claims for
noise induced hearing loss, the provisions of section 9.1, Chapter 9, “Ear,
Nose, Throat, and Related Structures,” are exempted from this rule. The
applicable exempt legislative rule has been promulgated for such claims.
67.3. In claims for
mental and emotional loss, the provisions of chapter 14, “Mental and Behavioral
Disorders,” are exempted from this rule. This rule shall be utilized.
67.4. In those claims
affected by the provisions of W. Va. Code §23-4-6(f), the degree of disability
stated there shall be applied.
67.5. In those claims
affected by the provisions of W. Va. Code §23-4-6(m), the conclusive
presumption of total disability stated there shall be applied.
§85-20-68. Payment for
Evaluations.
The Commission, Insurance Commissioner, private carrier or
self-insured employer, whichever is applicable, shall not make payment to any
impairment examiner whose reports, opinions, examinations, or evaluations are
not conducted, performed, and composed in accordance with this Rule. In the
event payment was made prior to a determination that the report, opinion,
examination, or evaluation was not conducted, performed, or composed in
accordance with this Rule, then the amount so paid shall be recovered from the
examiner either by way of a direct repayment to the Commission, Insurance
Commissioner, private carrier or self-insured employer, whichever is
applicable, or by way of an offset against any future sums that may be owed by
the Commission, Insurance Commissioner, private carrier or self-insured
employer, whichever is applicable, to the examiner for any services rendered
for or to the Commission, Insurance Commissioner, private carrier or
self-insured employer, whichever is applicable, or for or to an injured worker.
A later submission or supplement to the report, which demonstrates compliance
with these rules, shall serve to permit such payment.
§85-20-69. Violation and
Penalties:
Without limiting the general nature of various statutes
respecting criminal fraud, and by way of illustration and not in limitation,
the following are deemed unlawful acts and practices:
a. Billing for
services not actually performed;
b. Billing for
expenses not actually incurred;
c. Billing
services on dates other than the date on which they were actually performed;
d. Offering
consideration of any kind, including gifts, services or gratuities to
Commission, Insurance Commissioner, private carrier or self-insured employer,
whichever is applicable, employees in exchange for or as a past reward for
referring cases to the provider;
e. Failing to
close claims at the earliest practicable date when the injured worker can no
longer benefit from such services;
f. Providing
false information in any statement to the Commission, Insurance Commissioner,
private carrier or self-insured employer, whichever is applicable, or forging
or falsifying any record required to be kept by these Rules or any other
statute or rule governing providers; and
g. "Rolling
in" unreimbursable time or expenses by adding hours for billable time or
expenses.
All providers and employers shall retain for five (5)
years and provide to the Commission, Insurance Commissioner, private carrier or
self-insured employer, whichever is applicable, on request and without a
subpoena hard copies of the source underlying any bill, invoice, report, etc.
submitted to the Commission, Insurance Commissioner, private carrier or
self-insured employer, whichever is applicable, by electronic or other means.
§85-20-70. Injured Employee's
Responsibilities Concerning Medical Examination and Treatment. (Effective Date: -- February 1, 2005.)
70.1. Examination and
treatment.
The Commission, Insurance Commissioner, private carrier or
self-insured employer, whichever is applicable, may order an injured employee
to report for examination and may further order him to undergo such treatment
or hospitalization as is indicated in the particular case. It shall be the duty of the injured employee
to comply fully and promptly with any such order issued by the Commission,
Insurance Commissioner, private carrier or self-insured employer, whichever is
applicable.
70.2. Violation of
rule.
a. If violation
of any provision of this rule, or refusal to comply with any order of the
Commission, Insurance Commissioner, private carrier or self-insured employer,
whichever is applicable, issued as provided herein, should result in an
increase in the duration of temporary disability or in the degree of permanent
disability, such violation or refusal will be considered in determining the
compensation, if any, to be awarded and no compensation will be awarded for
extension or increase of disability caused thereby.
b. The
Commission, Insurance Commissioner, private carrier or self-insured employer,
whichever is applicable, may suspend benefits being paid to a claimant if the
claimant refuses, without good cause, to undergo or fully participate in the
examinations or needed treatments provided for in W. Va. Code §23-4-7a. Good cause shall consist of the following:
1.
Compelling evidence that the examination or treatment would have little,
if any, positive effect on the claimant’s injury;
2.
Compelling evidence that no ordinarily prudent and reasonable person
would have submitted to the examination or needed treatment;
3.
Compelling evidence that the examination or treatment would pose a
danger to the life or health of the claimant or require extraordinary
suffering;
4. A
consensus of medical opinions establishing that the examination or treatment
would not effect a cure or would not at least improve the likelihood that the
claimant could return to gainful employment; and
5.
Compelling evidence that the prognosis for success and recovery were
unreasonably low.
c. Failure to
attend a single scheduled examination or treatment shall not be grounds to
suspend benefits. However, failure to
attend two (2) or more consecutively scheduled examinations or treatments without
clear justification, regardless if the examinations or treatments were
scheduled for a related purpose, may, in the Commission’s, Insurance
Commissioner’s, private carrier’s or self-insured employer’s, whichever is
applicable, sole discretion, constitute
grounds to suspend benefits. Also, a
pattern of failing to attend scheduled examinations or treatments shall
constitute grounds for the suspension of benefits.
d. A claimant
whose benefits are suspended under this rule shall not be entitled to benefits from the date the relevant
examination or treatment was not undergone until such time as the examination
or treatment is undergone and notice of such is provided to the Commission,
Insurance Commissioner, private carrier or self-insured employer, whichever is
applicable. If benefits are
re-instated, any overpayment will be deducted from the re-instated benefits at
a reasonable rate until the overpayment is recouped. The unpaid balance of the overpayment, if any, will be recovered
from any future award to the claimant.
e. The
Commission, Insurance Commissioner, private carrier or self-insured employer,
whichever is applicable, shall enter a protestable order notifying the claimant
of the suspension of benefits and shall serve the order on all of the parties
to the claim.
§85-20-71. Severability.
If any provision of this Rule or the application thereof to any
entity or circumstance shall be held invalid, such invalidity shall not affect
the provisions or the applications of this Rule which can be given effect
without the invalid provisions or application and to this end the provisions of
this rule are declared to be severable.
TABLE 85-20A. Impairment of
Pulmonary Function. Page 1 of 3.
a. The following table will be used as an
indicator of impairment of pulmonary function if any of the acceptable values
appear in the percentage of impairment column:
% IMPAIRMENT:
0 10 15 20 25 30 40 50 60 TOTAL
FVC % PRED. 80 75 70 67 64 61 58 55 52 50
FEV1.% PRED. 75 73 70 67 64 61 58 55 52 50
FEV1./FVC 75 73 70 67 64 61 56 51 48 45
MVV % PRED. 80 75 70 67 64 61 58 55 52 50
PaCO2 Pa02 Values Equal to or Less Than
30 or below 85 81 78 75 73 70 68 67 66 65
31 84 80 77 74 72 69 67 66 65 64
32 83 79 76 73 71 68 66 65 64 63
33 82 78 75 72 70 67 65 64 63 62
34 81 77 74 71 69 66 64 63 62 61
35 80 76 73 70 68 65 63 62 61 60
36 79 75 72 69 67 64 62 61 60 59
37 78 74 71 68 66 63 61 60 59 58
38 77 73 70 67 65 62 60 59 58 57
39 76 72 69 66 64 61 59 58 57 56
40 or above 75 71 68 65 63 60 58 57 56 55
|
Impairment |
0% |
10-20% |
21-50% |
51-100% |
|
DL/VA |
> or = 80%pred |
60-79% pred |
41-59% pred |
< or = 40%pred |
TABLE
85-20A. Impairment of Pulmonary
Function. (page 2)
(b) Exercise p02
values that rise above the resting p02 values will indicate a lesser
degree of impairment of pulmonary function, and if they are less than the
resting values will indicate a greater degree of impairment of pulmonary
function.
(c) The results
of any medically acceptable tests or procedures reported by a physician which
are not addressed in this table but which tend to demonstrate the presence or
absence of pneumoconiosis or sequela of pneumoconiosis or the presence or
absence of a respiratory pulmonary impairment may be submitted and given
appropriate consideration (Airway Resistance, Oximetry, and A-a gradient,
etc.). It is also important that the
Occupational Pneumoconiosis Board use all clinical history and physical
findings that would enhance or detract from any percentage of impairment in the
above table.
(d) Where an
employee has a definitely ascertainable impairment which is not resulting from
occupational pneumoconiosis, but which is contributing to the employee's
over-all pulmonary impairment, such impairment, the effect thereof, and any
aggravation thereof will not be taken into consideration in fixing the amount
of compensation allowed for occupationalpneumoconiosis, and such compensation
will be awarded only in the amount that would have been allowable had such
other impairment not been present.
(e) The degree of
such impairment attributable to a cause that is not occupational pneumoconiosis
may be established at any time by competent medical or other evidence.
Competent medical or other evidence will include reasoned medical judgment that
is based on the medical record in a given claim and on generally accepted
medical science.
(f) The method of
establishing impairment attributable to a cause that is not occupational
pneumoconiosis need not be a matter of exact mathematical or scientific
formulation, but should based upon the entirety of the evidentiary record,
including but not limited to: 1) a recognition of the magnitude and type of
impairment that is typically associated with different types of pneumoconiosis;
2) a recognition of the magnitude and type of impairment typically associated
with medical conditions other than pneumoconiosis that cause pulmonary
impairment; 3) a recognition of the type, intensity and duration of the
physical insults that have given rise to any pneumoconiosis and other causes of
pulmonary impairment; and 4) a recognition that where two or more medical
conditions likely to cause pulmonary impairment exist in combination, every
effort should be made to fairly allocate responsibility for any over-all
pulmonary impairment among the several conditions. (g) Cigarette and cigar smoking are recognized by the medical
community as the principal causes of pulmonary impairment and primary lung
cancers in the general population. Special attention will be given to assuring
that, wherever possible, pulmonary impairment caused by cigarette or cigar
smoking is not included in awards for impairment cause by occupational
pneumoconiosis.
TABLE §85-20-A. Impairment of Pulmonary Function (page 3)
I. Ventilatory Function
Tests
A. FVC – Forced
Vital Capacity – Three adequate trials are required for a valid test. The two best curves must be within 7%. The
third curve should be of similar shape.
The largest FVC is to be reported.
B. FEV1
– Forced Expiratory Volume in one second – The largest FEV1 is to be
reported. The two best FEV1
measurements should be within 7%.
Extrapolated volume must be less that 10% of the FVC.
C. MVV – Maximum
Voluntary Ventilation – Must approximate the FEV1 X 40 to within 80%
to be a valid test.
D. Tracings – The three best curves from the
FVC maneuver must be provided. Multiple
trials may be illustrated to demonstrate non-reproducibility.
Tracings which reflect
non-valid studies should show all trials to indicate multiple attempts to
achieve validity.
E. Reports shall indicate the location of test,
date and time along with name of technician or other medical personnel
performing the test.
Report shall include the
patient/claimant’s last name, first and middle initial, social security number,
current age in years, gender, height measurement to the nearest ¼ inch, and
weight in pounds.
F. Test results are to be reported in BTPS.
G. Calibration reports from the date of testing
should also be provided.
H. Kory nomogram is to be used for predicted
values for spirometry.
I. Facilities providing services for the
Commission or Insurance Commissioner, whichever is applicable, may be subject
to inspection by an appointee of the Commission or Insurance Commissioner,
whichever is applicable. Pulmonary
Function Laboratories should be staffed with properly trained personnel, have
adequate equipment with documented calibration and quality control, and access
to related files. Personnel performing
spirometry must possess a minimum of a NIOSH training certificate. Personnel performing more complex pulmonary
function testing should possess a minimum of CPFT (Certified Pulmonary Function
Technician) with an RPFT (Registered Pulmonary Function Technologist) preferred.
II.
Arterial Blood Gas
A. Reports shall indicate resting and/or
exercise.
B. If resting only, there should be a noted
contraindication to exercise.
C. Reports shall indicate the location,
altitude, and barometric pressure of testing facility, date and time along with
name of technician or other medical personnel performing the test.
D. Facilities
performing blood analysis must provide evidence of compliance with CLIA
regulations and be subject to inspection by authorized personnel.
III. Chest X-ray
A. Singleview –
PA – Upright at full inspiration on a 14 x 17 film is required.
B. Film should be
identified with location of testing facility, date, patient name, SSN, and date
of birth.
C. Original films
should be provided for review.
D. Facilities
performing radiographic services must provide evidence of compliance with state
and federal laws regulating such facilities and be subject to inspection by
authorized personnel.
TABLE §85-20-B. Schedule of Controlled Substances.
a. The Controlled
Substances Act of 1970 regulates the manufacturing, distribution and dispensing
of drugs that have abuse potential. The
Drug Enforcement Administration (DEA) within the US Department of Justice is
the chief federal agency responsible for enforcement.
A. DEA
Schedules: Drugs under jurisdiction of
the Controlled Substances Act are divided into five schedules based on their
potential for abuse and physical and psychological dependence. All controlled substances listed in Drug
Facts and Comparisons are identified by schedule as follows:
Schedule I (C-I) High
abuse potential and no accepted medical use (e.g., heroin, marijuana, LSD).
Schedule II (C-II) High
abuse potential with severe dependence liability (eg, narcotics, amphetamines,
dronabinol, some barbiturates).
Schedule III (C-III) Less
abuse potential than schedule II drugs and moderate dependence liability (eg,
nonbarbiturate sedatives, nonamphetamine stimulants, limited amounts of certain
narcotics).
Schedule IV (C-IV) Less
abuse potential than schedule III drugs and limited dependence liability (eg,
some sedatives, antianxiety agents, non-narcotic analgesics).
Schedule V (C-V) Limited
abuse potential. Primarily small
amounts of narcotics (codeine) used as antitussives or antidiarrheals. Under federal law, limited quantities of
certain c-v drugs may be purchased without a prescription directly from a
pharmacist if allowed under specific state statutes. The purchaser must be at least 18 years of age and must furnish
suitable identification. All such
transactions must be recorded by the dispensing pharmacist.
TABLE §85-20-C. PPD Ranges for
Lumbar Spine Impairments
|
Criteria for Rating
Impairment Due to Lumbar Spine Injury |
||||
|
Lumbar Category I 0% Impairment of the Whole Person |
Lumbar Category II 5%-8% Impairment of the Whole Person |
Lumbar Category III 10%-13% Impairment of the Whole Person |
Lumbar Category IV 20%-23% Impairment of the Whole Person |
Lumbar Category V 25%-28% Impairment of the Whole Person |
|
No significant clinical
findings, no observed muscle guarding or spasm, no documentable neurologic
impairment, no documented alteration in structural integrity and no other
indication of impairment related to injury or illness; no fractures |
Clinical history and
examination findings are compatible with a specific injury; findings may
include significant muscle guarding or spasm observed at the time of the
examination, asymmetric loss of range of motion, or nonverifiable radicular
complaints, defined as complaints of radicular pain without objective
findings; no alteration of the structural integrity and no significant
radiculopathy or individual had a clinically
significant radiculopathy and has an imaging study that demonstrates a
herniated disk at the level and on the side that would be expected based on
the previous radiculopathy, but no longer has the radiculopathy following
conservative treatment or fractures: (1) less than 25% compression of one
vertebral body; (2) posterior element fracture without dislocation (not
developmental spondylolysis) that has
healed without alteration of motion segment integrity; (3) a spinous
or transverse process fracture with displacement without a vertebral body
fracture, which does not disrupt the spinal canal |
Significant signs of
radiculopathy, such as dermatormal pain and/or in a dermatomal distribution,
sensory loss, loss of relevant reflex(es), loss of muscle strength or
measured unilateral atrophy above or below the knee compared to measurements
on the contralateral side at the same location; impairment may be verified by
electrodiagnostic findings or history of a herniated disk
at the level and on the side that would be expected from objective clinical
findings, associated with radiculopathy, or individuals who had surgery for radiculopathy but are now
asymptomatic or fractures: (1) 25% to 50% compression of one
vertebral body; (2) posterior element fracture with displacement disrupting
the spinal canal; in both cases, the fracture has healed without alteration
of structural integrity |
Loss of motion segment
integrity defined from flexion and extension radiographs as at least 4.5 mm
of translation of one vertebra on another or angular motion greater than 15°
at L1-2, L2-3 and L3-4, greater than 20° at L4-5, and greater than 25° at
L5-S1 (Figure 15-3); may have complete or near complete loss of motion of a
motion segment due to developmental fusion, or successful or unsuccessful
attempt at surgical arthrodesis or fractures: (1) greater than 50% compression of one
vertebral body without residual neurologic compromise |
Meets the criteria of DRE
lumbosacral categories III and IV; that is, both radiculopathy and alteration
of motion segment integrity are present; significant lower extremity
impairment is present as indicated by atrophy or loss of reflex(es), pain
and/or sensory changes within an anatomic distribution (Dermatomal), or
electromyographic findings as stated in lumbosacral category III and
alteration of spine motion segment integrity as defined in lumosacral category
IV or fractures: (1) greater than 50% compression of one
vertebral body with unilateral neurologic compromise |
TABLE §85-20-D. PPD Ranges for
Thoracic Spine Injury
|
Criteria for Rating
Impairment Due to Thoracic Spine Injury |
||||
|
Thoracic
Category I 0% Impairment
of the Whole Person |
Thoracic
Category II 5%-8%
Impairment of the Whole Person |
Thoracic
Category III 15%-18% Impairment of the Whole Person |
Thoracic
Category IV 20%-23% Impairment of the Whole Person |
Thoracic
Category V 25%-28% Impairment of the Whole Person |
|
No significant clinical
findings, no observed muscle guarding, no documentable neurologic impairment,
no documented changes in structural integrity and no other indication of
impairment related to injury or illness; no fractures |
History and examination
findings are compatible with a specific injury or illness; findings may
include significant muscle guarding or spasm observed at the time of the
examination, asymmetric loss of range of motion (dysmetria), or nonverifiable
radicular complaints, defined as complaints of radicular pain without
objective findings; no alteration of motion segment integrity or herniated disk at the level
and on the side that would be expected from objective clinical findings, but
without radicular signs following conservative treatment or fractures: (1) less than 25% compression of one
vertebral body; (2) posterior element fracture without dislocation that
has healed without alteration of
motion segment integrity or radiculopathy; (3) a spinous or transverse
process fracture with displacement, but without a vertebral body fracture |
Ongoing neurologic
impairment of the lower extremity related to a thoracolumbar injury,
documented by examination of motor and sensory functions, reflexes or
findings of unilateral atrophy above or below the knee related to no other
condition; impairment may be verified by electrodiagnostic testing or clinically significant
radiculopathy, verified by an imaging study that demonstrates a herniated
disk at the level and on the side that would be expected from objective
clinical findings; history of radiculopathy, which has improved following
surgical treatment or fractures: (1) 25% to 50% compression fracture of one
vertebral body; (2) posterior element fracture with mild displacement
disrupting the canal; in both cases the fracture has healed without
alteration of structural integrity; differentiation from a congenital or
developmental condition should be accomplished, if possible, by examining
preinjury roentgenograms, if available, or by a bone scan performed after the
onset of the condition |
Alteration of motion
segment integrity or bilateral or multilevel radiculopathy; alteration of
motion segment integrity is defined from flexion and extension radiographs as
translation of one vertebra or another of more than 2.5 mm; radiculopathy as
defined in thoracic category III need not be present if there is alteration
of motion segment integrity; if an individual is to be placed in DRE thoracic
category IV due to radiculopathy, the latter must be bilateral or involve
more than one level or fractures: (1) more than 50% compression of one
vertebral body without residual neural compromise |
Impairment of the lower
extremity as defined in thoracolumbar category III and loss of structural
integrity as defined in thoracic category IV or fractures: (1) greater than 50% compression of one
vertebral body with neural motor compromise but not bilateral involvement
that would qualify the individual for corticospinal tract evaluation |
TABLE §85-20-E. PPD Ranges for
Cervical Disorders
class=Section8>
|
Table 15-5
Criteria for Rating Impairment Due to Cervical Disorders |
||||
|
Cervical
Category I 0%
Impairment of the Whole Person |
Cervical
Category II 5%-8%
Impairment of the Whole Person |
Cervical
Category III 15%-18% Impairment of the Whole Person |
Thoracic
Category IV 25%-28% Impairment of the Whole Person |
Thoracic
Category V 35%-38% Impairment of the Whole Person |
|
No significant clinical findings, no
muscular guarding, no documentable neurologic impairment, no significant loss
of motion segment integrity and no other indication of impairment related to
injury or illness; no fractures |
Clinical history and examination
findings are compatible with a specific injury; findings may include muscle
guarding or spasm observed at the time of the examination by a physician,
asymmetric loss of range of motion or
nonverifiable radicular complaints, defined as complaints of radicular pain
without objective findings; no alteration of the structural integrity or individual had clinically significant
radiculopathy and an imaging study that demonstrated a herniated disk at the
level and on the side that would be expected based on the radiculopathy, but
has improved following nonoperative treatment or fractures: (1) less than 25% compression of one vertebral body; (2)
posterior element fracture without dislocation that has healed without loss of structural
integrity or radiculopathy; (3) a spinous or transverse process fracture with
displacement |
Significant signs of radiculopathy, such
as pain and/or sensory loss in a dermatomal distribution, loss of relevant
reflex(es), loss of muscle strength, or unilateral atrophy compared with the
unaffected side, measured at the same distance above or below the elbow; the
neurologic impairment may be verified by electrodiagnostic findings or individual had clinically significant
radiculopathy, verified by an imaging study that demonstrates a herniated
disk at the level and on the side expected from objective clinical findings
with radiculopathy or with improvement of radiculopathy following surgery or fractures: (1) 25% to 50% compression of one vertebral bogy; (2) posterior
element fracture with displacement disrupting the spinal canal; in both cases
the fracture is healed without loss of structural integrity; radiculopathy
may or may not be present; differentiation from congenital and developmental
conditions may be accomplished, if possible, by examining preinjury
roentgenograms or a bone scan performed after the onset of the condition |
Alteration of motion segment integrity
or bilateral or multilevel radiculopathy; alteration of motion segment
integrity is defined from flexion and extension radiographs as at least 3.5
mm of translation of one vertebra on another, or angular motion of more than
11° greater than at each adjacent level (Figures 15-3a and 15-3b);
alternatively, the individual may have loss of motion of a motion segment due
to a developmental fusion or successful or unsuccessful attempt at surgical
arthrodesis; radiculopathy as defined in cervical category III need not be
present if there is alteration of motion segment integrity or fractures: (1) more than 50% compression of one vertebral body without
residual neural compromise |
Significant upper extremity impairment
requiring the use of upper extremity external functional or adaptive
device(s); there may be total neurologic loss at a single level or severe,
multilevel neurologic dysfunction or fractures: structural compromise of the spinal canal is present with
severe upper extremity motor and sensory deficits but without lower extremity
involvement |
Appendix §85-20-F
The Physical
Demands Strength Rating, as defined in the Dictionary of Occupational Titles,
is expressed by one of five terms:
Sedentary, Light, Medium, Heavy and Very Heavy. In order to determine the overall rating,
the injured worker’s abilities in the following activities must be
considered: Standing, Walking, Sitting,
Lifting, Carrying, Pushing, Pulling and Controls operation.
Standing means
remaining on one's feet in an upright position at a work station without moving
about.
Walking means
moving about on foot.
Sitting means
remaining in a seated position.
Lifting means
raising or lowering an object from one level to another (includes upward
pulling).
Carrying means
transporting an object, usually holding it in the hands or arms, or on the
shoulder.
Pushing means
exerting force upon an object so that the object moves away from the force
(includes slapping, striking, kicking and treadle actions).
Pulling means
exerting force upon an object so that the object moves toward the force
(includes jerking).
Lifting, pushing
and pulling are evaluated in terms of both intensity and duration.
Consideration is given to the weight handled, position of the worker's body and
the aid given by helpers or mechanical equipment. Carrying most often is
evaluated in terms of duration, weight carried and distance carried.
Controls entail
the use of one or both arms or hands (hand/arm) and/or one or both feet or legs
(foot/leg) to move controls on machinery or equipment. Controls include but are
not limited to buttons, knobs, pedals, levers and cranks.
Occasionally
means an activity or condition exists up to one third (1/3) of the time.
Frequently means
an activity or condition exists from one-third (1/3) up to two- thirds (2/3) of
the time.
Constantly means
an activity or condition exists two-thirds (2/3) or more of the time.
Sedentary Work -
Exerting up to 10 pounds of force occasionally and/or a negligible amount of
force frequently to lift, carry, push, pull, or otherwise move objects,
including the human body. Sedentary
work involves
sitting most of the time, but may involve walking or standing for brief periods
of time. Jobs are sedentary if walking and standing are required only
occasionally and all other sedentary criteria are met.
Light Work -
Exerting up to 20 pounds of force occasionally and/or up to 10 pounds of force
frequently and/or a negligible amount of force constantly to move objects.
Physical demand requirements are in excess of those for Sedentary Work. Even
though the weight lifted may be only a negligible amount, a job should be rated
Light Work: (1) when it requires walking or standing to a significant degree;
or (2) when it requires sitting most of the time but entails pushing and/or
pulling of arm or leg controls; and/or (3) when the job requires working at a
production rate pace entailing the constant pushing and/or pulling of materials
even though the weight of those materials is negligible. NOTE: The constant
stress and strain of maintaining a production rate pace, especially in an
industrial setting, can be and is physically demanding of a worker even though
the amount of force exerted is negligible.
Appendix §85-20-F (page 2)
Medium Work -
Exerting 20 to 50 pounds of force occasionally and/or 10 to 25 pounds of force
frequently and/or greater than negligible up to 10 pounds of force constantly
to move objects. Physical Demand requirements are in excess of those for Light
Work.
Heavy Work -
Exerting 50 to 100 pounds of force occasionally and/or 25 to 50 pounds of force
frequently and/or 10 to 20 pounds of force constantly to move objects. Physical
Demand requirements are in excess of those for Medium Work.
Very Heavy Work
- Exerting in excess of 100 pounds of force occasionally and/or in excess of 50
pounds of force frequently and/or in excess of 20 pounds of force constantly to
move objects. Physical Demand requirements are in excess of those for Heavy
Work.
Additional
physical demands of work, as defined in the Revised Handbook for Analyzing
Jobs, include Climbing, Balancing, Stooping, Kneeling, Crouching, Crawling,
Reaching, Handling, Fingering and Feeling.
Climbing means
ascending or descending ladders, stairs, scaffolding, ramps, poles and the
like, using feet and legs or hands and arms. Body agility is emphasized.
Appendix §85-20-F (page 3)
Balancing means
maintaining body equilibrium to prevent falling when walking, standing,
crouching, or running on narrow, slippery, or erratically moving surfaces; or
maintaining body equilibrium when performing gymnastic feats.
Stooping means
bending the body downward and forward by bending spine at the waist, requiring
full use of the lower extremities and back muscles.
Kneeling means
bending the legs at knees to come to rest on knee or knees.
Crouching means
bending the body downward and forward by bending legs and spine.
Crawling means
moving about on hands and knees or hands and feet.
Reaching means
extending hand(s) and arm(s) in any direction.
Handling means seizing,
holding, grasping, turning, or otherwise working with hand or hands. Fingers
are involved only to the extent that they are an extension of the hand, such as
to turn a switch or shift automobile gears.
Fingering means
picking, pinching, or otherwise working primarily with fingers rather than with
the whole hand or arm as in handling.
Feeling means
perceiving attributes of objects, such as size, shape, temperature, or texture,
by touching with skin, particularly that of fingertips.
EXHIBIT A
PSYCHIATRIC DIAGNOSES (WITH CORRESPONDING INTERNATIONAL
CLASSIFICATION OF DISEASES, NINTH REVISION CODES) NOT CONTRIBUTED TO BY A
WORK-RELATED INJURY
THE ONSET OF THE
FOLLOWING DIAGNOSES ARE, BY DEFINITION, NOT SIGNIFICANTLY CONTRIBUTED TO BY A
WORK-RELATED INJURY UNLESS THE DISORDER ENDS IN THE PHRASE “DUE TO A GENERAL
MEDICAL CONDITION” WHERE THE GENERAL MEDICAL CONDITION IS CAUSED BY THE WORK
RELATED INJURY. ALTHOUGH THESE DIAGNOSES MAY BE PRESENT IN AN INDIVIDUAL AND
THESE DIAGNOSES SHOULD BE CONSIDERED IN APPORTIONMENT, UNLESS SPECIFICALLY
EXCEPTED IN WRITING, THESE DIAGNOSES SHOULD NOT RECEIVE AN IMPAIRMENT RATING.
Disorders
Usually First Diagnosed in Infancy, Childhood, or Adolescence
Mental
Retardation (317, 318.x, 319)
Learning
Disorders (315.x, 315.xx)
Motor Skills
Disorder (315.4)
Communication
Disorders (315.xx, 307.x)
Pervasive
Development Disorders (299.x, 299.xx)
Attention-Deficit
and Disruptive Behavior Disorders (314.xx, 314.9)
Feeding and
Eating Disorders of Infancy or Early Childhood (307.xx)
Tic Disorders
(307.xx)
Elimination
Disorders (307.x, 787.6)
Other Disorders
of Infancy, Childhood, or Adolescence (309.21, 313.89, 307.3, 313.9)
Delirium,
Dementia, and Amnestic and Other Cognitive Disorders
All (except for
Cognitive Disorder, NOS) (294.xx, 290.xx, 294.1, 294.8, 293.89)
Substance-Related
Disorders
All (303.xx,
291.x, 291.xx, 304.xx, 305.x, 305.xx, 292.xx, 292.x)
Schizophrenia
and Other Psychotic Disorders
All (295.xx,
297.x, 298.x, 293.xx)
Mood Disorders
All Bipolar
Disorders (296.0x, 296.4x, 296.5x, 296.6x, 296.7, 296.89, 296.80, 296.90)
Cyclothymic
Disorder (301.13)
Anxiety
Disorders
Social Phobia
(300.23)
Obsessive-Compulsive
Disorder (300.3)
Generalized
Anxiety Disorder (300.02)
Somatoform
Disorders
All (300.8x,
300.11, 307.xx, 300.7, 300.82) (except Pain Disorder)
Factitious
Disorders
All (300.16,
300.19)
Dissociative
Disorders
All (300.12,
300.13, 300.14, 300.6, 300.15) (except Dissociative Disorder, NOS)
Sexual and
Gender Identity Disorders
All (302.7x,
306.51, 302.4, 302.8x, 302.2, 302.3, 302.9, 302.6, 302.85, 302.6, 302.9)
Eating Disorders
All (307.1,
307.51, 307.50)
Sleep Disorders
All (307.4x,
347, 780.59)
Impulse-Control
Disorders Not Elsewhere Classified
All (312.3x)
Personality
Disorders
All (301.x,
301.xx)
Other Conditions
That May Be A Focus Of Clinical Attention (316, All “V” Codes, 780.9, 313.82,
300.9, 799.9)
EXHIBIT B
WEST VIRGINIA WORKERS’ COMPENSATION DIVISION
Impairment Guideline for RATING
Psychiatric Impairment
Exhibit B shall
be used to determine a claimant's psychiatric impairment rating using the
classification consistent with the AMA Guides to the Evaluation of Permanent
Impairment, Fifth Edition, in conjunction with the Axis V Global Assessment of
Functioning Scale (GAF, DSM-IV-TR 2000, page 34), the claimant's treatment
needs, and functional status. Axis V
refers only to psychological, occupational, and social functioning and the
examiner must NOT include impairment in functioning as a result physical
limitations in the formulation of the GAF (GAF, DSM-IV-TR 2000).
Disorders
believed to have resulted from brain injury, such as cognitive disorders,
should NOT be rated using this guideline, but should be evaluated according to
relevant sections of Chapter 4 of the AMA Guides to the Evaluation of Permanent
Impairment, Fourth Edition.
The diagnoses of
Pain Disorder and Dissociative Disorder, NOS, while important in the
presentation and treatment of the underlying physical condition, should not
receive an impairment rating.
The impairment
percentage may only be determined after the claimant has reached maximum
medical improvement. Rows 1-5 should
guide the examiner to an impairment classification in row 6 with the
corresponding whole person impairment percentage range in row 7. Within each class, the examiner must justify
the specific choice of rating along the range based on information in rows 1-5
to formulate an overall impairment rating.
This rating should then be apportioned to account for pre-existing or
non work-related contributors as noted in the Guideline for Psychiatric
Independent Medical Examination – Report Online (Exhibit C).
|
1. GAF |
2. Symptom Severity |
3. Level of Functioning |
4. Treatment Needs |
5. ADLs, Social Functioning, Concentration, Adaptation |
6. Impairment Classification |
7. Whole person impairment |
|
|
|
100-91 |
No symptoms. |
Superior
functioning in a wide range of activities, life’s problems never seem to get
out of hand, is sought out by others because of his or her many positive
qualities. |
None or
infrequent outpatient treatment |
No Impairment |
Class 1: No
Impairment |
0% |
|
|
|
90-81 |
Absent or
minimal symptoms (e.g., mild anxiety before an exam). Generally satisfied
with life, no more than everyday problems or concerns (e.g., an occasional
argument with family members). |
Good functioning
in all areas, interested and involved in a wide range of activities, socially
effective. |
None or
infrequent outpatient treatment |
No Impairment |
Class 1: No
Impairment |
0% |
|
|
|
80-71 |
If symptoms
are present, they are transient and expectable reactions to psychosocial
stressors (e.g., difficulty concentrating after family argument). |
No more than
slight impairment in social or occupational functioning (e.g., temporarily
falling behind in work). |
None or
infrequent outpatient treatment |
No Impairment |
Class 1: No
Impairment |
0% |
|
|
|
70-61 |
Some mild
symptoms (e.g., depressed mood and mild insomnia). -OR- |
Impairment
levels are compatible with most useful functioning. Some difficulty in social or occupational functioning (e.g.,
occasional absences or theft within the household), but generally functioning
pretty well, has some meaningful interpersonal relationships. |
None or
infrequent outpatient treatment |
Impairment
levels are compatible with most useful functioning |
Class 2: Minimal Impairment |
0-5% |
|
|
|
60-51 |
Moderate
symptoms (e.g., flat affect and circumstantial speech, occasional panic
attacks) -OR- |
Impairment
levels are compatible with some, but not all, useful functioning. Moderate difficulty in social or
occupational functioning (e.g., few friends, conflicts with co-workers). |
Continuous
outpatient treatment |
Impairment
levels are compatible with some, but not all, useful functioning |
Class 3: Mild Impairment |
6-14% |
|
|
|
50-41 |
Serious
symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent
shoplifting). -OR- |
Impairment
levels significantly impede useful functioning. Requires direction and supervision in the performance of
ADL's. Any serious impairment in
social or occupational functioning (e.g., no friends, unable to keep a job). |
Intensive
outpatient treatment, day hospital, occasional to frequent inpatient
hospitalization. |
Impairment
levels significantly impede useful functioning |
Class 4: Moderate Impairment |
15-29% |
|
|
|
40-31 |
Some
impairment in reality testing or communication (e.g., speech is at times
illogical, obscure, or irrelevant). -OR- |
Major
impairment in several areas, such as work, family relations, judgment,
thinking, or mood (e.g., depressed man avoids friends, neglects family and is
unable to work). |
Intensive
outpatient treatment, day hospital, occasional to frequent inpatient
hospitalization. |
Impairment
levels significantly impede useful functioning |
Class 4: Moderate Impairment |
15-29% |
|
|
|
30-21 |
Behavior is
considerably influenced by delusions or hallucinations - OR - serious
impairment in communication or judgment (e.g., sometimes incoherent, acts
grossly inappropriately, suicidal preoccupation) |
Inability to
function in almost all areas (e.g., stays in bed all day, no job, home or
friends). |
Permanently in
assisted living to complete institutionalization |
Impairment
levels preclude useful functioning |
Class 5a: Severe Impairment |
30-49% |
|
|
|
20-11 |
Some danger of
hurting self or others (e.g., suicide attempts without clear expectation of
death; frequently violent; manic excitement) -OR- Gross impairment in
communication (e.g., largely incoherent or mute) |
Occasionally
fails to maintain minimal personal hygiene (e.g., smears feces). |
Permanently in
assisted living to complete institutionalization |
Impairment
levels preclude useful functioning |
Class 5b: Very Severe Impairment |
50-70% |
|
|
|
10-0 |
Persistent
danger of severely hurting self or others (e.g., recurrent violence) -OR-
serious suicidal act with clear expectation of death. |
Persistent
inability to maintain minimal personal hygiene. |
Permanently in
assisted living to complete institutionalization |
Impairment
levels preclude useful functioning |
Class 5b: Very Severe Impairment |
50-70% |
|
|
|
|
|
|
|
|
|
|
|
|
EXHIBIT
C
WEST VIRGINIA WORKERS’ COMPENSATION COMMISSION
GUIDELINE FOR PSYCHIATRIC INDEPENDENT MEDICAL EXAMINATION –
REPORT OUTLINE
The following is an outline of the standard psychiatric
independent medical examination report.
The bolded items should be addressed in every report to ensure
consistency. Although there is no
substitute for quality clinical assessment, the areas subsumed under each
bolded section should also be addressed when possible. Note that each area allows for both
subjective and objective data, therefore attention to the application of data to
Workers’ Compensation issues should be emphasized. The italicized language represents commentary to aid in
clarification of the outline.
I Identifying
Data
Claimant Name:
Social Security Number:
Date of Birth:
Claim Number(s):
Date of Injury:
Date of Interview:
Date of Report:
II Consent
Be sure to include a statement about
the following:
the nature and purpose
of the examination,
that the examiner is a
psychiatrist,
that the
examination is for the purpose of WV Workers’ Compensation Division,
that there is an
inherent lack of confidentiality,
that a written report
will be issued to the WV Workers’ Compensation Division,
that the examiner may be
asked to provide information in court or directly
to the WV Workers’
Compensation Division
that the examiner will
not be treating the claimant, but may express
management
recommendations that may influence their care indirectly, and
that no
physician-patient relationship will be established.
III Chief
Complaint
IV History of
Present Illness
A. Injury
Provide the claimant’s account of
the injurious event. Include the
following:
1. Employer name
2. Position or job title
3. Duties and responsibilities, including
supervisory duties
4. Whether injury occurred in the usual
course of employment
5. Whether claimant was working at an
outside position (that is, not with the employer) or was self employed
6. Events leading up to injury
7. Events of injury including:
a. How injury occurred
b. Whether others were injured
c. Whether there were any witnesses to
injury
8. Events following injury, including:
a. When medical care was sought
b. Where medical care was sought
c. Means of arriving to medical care
9. Whether,
at time of interview, physical symptoms are worse, better, or same since
injury.
B. Psychiatric Information
For each diagnosis,
include the following information:
A. Name of diagnosis with modifiers,
specifiers, remission status and subtypes as per the most recent edition of the
Diagnostic and Statistical Manual of Disorders of the American Psychiatric
Association
B. Criterion-based support for the
diagnosis
C. Associated support for diagnosis
including:
1. Non-criteria
signs and symptoms
2. Diagnoses
made by other clinicians that support the current diagnosis.
D. Onset date of diagnosis when minimal
criteria were met (estimate if necessary)
E. Course of diagnosis since onset to time
of interview
F. Severity of diagnosis around time of
interview (mild, moderate, severe)
G. Past management, with outcomes
including:
1. Medications
or other biological treatment with doses and duration