PERMANENT RULES
LABOR AND INDUSTRIES
Date of Adoption: December 7, 1999.
Purpose: Drugs and medication, chapter 296-20 WAC, the purpose of this rule is to clearly describe which drugs are a covered benefit on claims for injured and ill workers and victims of crime.
Citation of Existing Rules Affected by this Order: Repealing WAC 296-20-03003; and amending WAC 296-20-030.
Statutory Authority for Adoption: RCW 51.04.020, 51.04.030.
Adopted under notice filed as WSR 99-19-164 on September 22, 1999.
Changes Other than Editing from Proposed to Adopted Version: Changes were made to nine of the WAC sections for clarification and/or in response to comments received at the public hearing.
WAC Created: WAC 296-20-03010 through 296-20-03024, Drug coverage rules.
WAC Amended: WAC 296-20-030 Treatment not requiring authorization for accepted conditions.
WAC Repealed: WAC 296-20-03003 Drugs and medication.
Reasons for Adopting the Rule Change: Generally, medical coverage decisions do not constitute a "rule" as used in RCW 34.05.010(16), nor are such decisions subject to the rule-making provisions of chapter 34.05 RCW. RCW 51.04.030(1). However, the department chose to rewrite the drug coverage rules for two main reasons:
(1) The revisions to the drug coverage rules are clearer and easier to understand. This satisfies the requirements of Executive Order No. 97-02.
(2) Portions of the language in current WAC 296-20-03003 had become obsolete and/or out of sync with current prescribing practices. For example, the prescribing practices for the use of opioids to treat chronic pain have changed. The revisions reflect current medical standards and the limitations concerning what the insurer may pay for under the Industrial Insurance Act, Title 51 RCW. See RCW 51.36.010; 51.36.100; 51.04.020; the Department of Health Guidelines for Management of Pain; and, the Guidelines for Outpatient Prescription of Oral Opioids for Injured Workers with Chronic, Non-Cancer Pain, developed by the department in conjunction with Washington State Medical Association Industrial Insurance and Rehabilitation Committee.
Summary of Comments Received, Department Responses, and
Changes to the Rule: The language that is underlined in the
"Changes to the Proposed Rule" portion of this document indicate
revisions to the proposed rule based on public comment. Editing
changes to the proposed rules are not listed below.
Response: See specific changes and comments in WAC 296-20-03020 and 296-20-03021.
WAC 296-20-030 Treatment not requiring authorization for accepted conditions.
Comment: Specific procedures (e.g. iontophoresis) should not be listed in this WAC because the language will become out-of-date.
Response: This particular WAC was not reviewed in its entirety. At this time, we only focused on deleting the language on drug coverage issues to prevent duplication on those issues that are in the new WAC sections. The rest of this WAC, including the statement on iontophoresis will be reviewed for possible amendment in the next 1-2 years.
WAC 296-20-03010 What are the general principles the department uses to determine coverage on drugs and medications?
Comment: The department should change the language to say it covers all FDA approved drugs and devices for stated indications.
Response: The suggested change was not made. There are some drugs used only for conditions that are not industrial injuries or illnesses. In addition, since these new WACs focus only on drugs, we did not add "devices" as requested.
WAC 296-20-03011 What general limitations are in place for medications?
Comment: Opioids should be a covered treatment on pension cases.
Response: The suggested change was not made. There is a statutory restriction that says the department can not pay for schedule I-IV substances used to alleviate continuing pain on pension cases (RCW 51.36.010).
WAC 296-20-03012 Where can I find the department's outpatient drug and medication coverage decisions?
Comment: Non-FDA approved drugs should be listed under the denied category.
Response: The suggested change was not made. Within this country, that is a good suggestion. However, we have injured workers that move outside of this country. There are times that their physicians will prescribe drugs which are similar to FDA-approved drugs but have not been approved by the FDA since they are not marketed in this country.
WAC 296-20-03014 Which drugs have specific limitations?
(1) Injectables
Comment: If the doctor feels that an injectable medication is what the patient needs, DLI should cover it.
Response: The suggested change was not made. Injectable drugs enter the system much more rapidly than those that are taken orally in pill form. For this reason, the department is concerned about the increased possibility of immediate adverse reactions and the increased potential for drug dependency.
Comment: If a physician determines it is necessary to admit an injured worker to a hospital solely for the administration of drugs for relief of chronic pain, this should be covered, whether oral or injectable.
Response: We added the following change to the proposed rule in response to this and similar comments and to be consistent with current law.
Change to the Proposed Rule: (1) Injectables.
Prescriptions for injectable narcotics opioids or other
analgesics, sedatives, analgesics, antihistamines, tranquilizers,
psychotropics, vitamins, minerals, food supplements, and hormones
are not covered.
Exceptions: The department or self-insurer covers injectable medications under the following circumstances.
(a) Indicated injectable drugs for the following:
| • | Inpatients |
| • | During emergency treatment of a life-threatening condition/injury; or |
| • | During outpatient treatment of severe soft tissue injuries, burns or fractures when needed for dressing or cast changes; or |
| • | During the perioperative period and the postoperative period, not to exceed forty-eight hours from the time of discharge. |
(2) Noninjectables
Comment: Patches should be covered.
Response: This section pertains to drugs that are administered in some form other than pills or injections (e.g. nasal sprays, patches). The department's concerns are similar to those stated for injectables. The language is written in such a way to allow for alternative routes of administration if the drug does not enter the system as quickly as injectables. This language will allow the department to look at each drug/route of administration on a case by case basis.
(3) Sedative-hypnotics
Comment: The exception for anti-seizure medications is inaccurate and should not be here.
Response: Change made.
Change to the Proposed Rule: (3) Sedative-hypnotics. During the chronic stage of an industrial injury or occupational disease, payment for scheduled sedatives and hypnotics will not be authorized.
Exception: Anti-seizure medications.
WAC 296-20-03015 What steps may the insurer take when concerned about the amount or appropriateness of drugs and medications prescribed to the injured worker?
Comment: In requesting that the attending physician consider reducing the prescription and provide chemical dependency programs, the inference is that injured workers who take opioids will become addicted. This is an outdated assumption.
Response: No change was made. This section refers to all drugs, not just opioids.
Comment: The department should not be in the business of telling doctors how to practice medicine.
Response: No change was made. The department as a trustee of the medical aid fund has a duty to supervise the provision of proper and necessary medical care to injured and ill workers. The steps listed are already in rule and have simply been placed into one WAC for clarity. These steps are options that the insurer may use to ensure appropriate medical care for the injured worker.
WAC 296-20-03016 Is detoxification and/or chemical dependency treatment covered?
Comment: This section is not clear. Does someone have to be dependent and have an addiction?
Response: This section was rewritten for clarity.
Change to the Proposed Rule: The department or self-insurer may pay for detoxification and/or chemical dependency treatment in the following circumstances:
| • | The injured worker becomes dependent or toxic on medication prescribed for an accepted condition on the claim; or |
| • | The injured worker becomes dependent or toxic due to
medications prescribed for a condition retarding recovery of
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| • | The injured worker is dependent or toxic due to medications for an unrelated condition, but that dependency or toxicity is retarding recovery of the accepted condition. |
Comment: Chronic pain does not always start within the two-four month window. Suggest adding the word "typically."
Response: Thanks for the suggestion. Change made.
Change to the Proposed Rule: 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.
WAC 296-20-03020 What are the authorization requirements for treatment of chronic, noncancer pain with opioids?
Comment: The authorization and documentation requirements on opioids for chronic, noncancer pain are overly burdensome. They will prevent some doctors from appropriately treating workers and/or delay appropriate treatment for workers in pain.
Response: The requirements listed are necessary for the department to ensure that the treatment of chronic, noncancer pain with opioids is proper and necessary, as defined in WAC 296-20-01002. Further, the documentation requirements are consistent with recommendations contained in the Department of Health Guidelines for Management of Pain (see, for example, Section F, Guidelines for Assessment and Documentation in Non-Cancer Pain; and Section G, Patient Responsibilities). However, the department made some changes in response to this concern. The proposed rules required prior authorization to treat chronic, noncancer pain with opioids. The final rules still require authorization but give the physician a thirty day grace period to submit the initial report. In addition, record review has been reduced to a consideration of the patient's relevant medical history. See below.
Comment: What are elements of addiction?
Response: This bullet was rewritten for clarity. See below.
Change to the Proposed Rule: Prior authorization is
required for treatment of chronic, noncancer pain with opioids.
No later than 30 days after the attending physician begins
treating the worker with opioids for chronic, noncancer pain,
tThe attending physician must submit a written request report to
and obtain approval from the department or self-insurer in order
for the department or self-insurer to pay for such treatment.
prior to prescribing opioids for chronic, noncancer pain. The
written report request must include the following factors:
| • | A treatment plan with time-limited goals; |
| • | A consideration of relevant prior medical history; |
| • | A summary of conservative care rendered to the worker that focused on reactivation and return to work; |
| • | A statement on why prior or alternative conservative measures may have failed or are not appropriate as sole treatment; |
| • | A summary of any consultations that have been obtained, particularly those that have addressed factors that may be barriers to recovery; |
| • | A statement that the attending physician has conducted
appropriate screening for |
| • | 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. |
Comment: Will physicians be compensated for these new reports?
Response: Since the fee schedule is not in rule, billing codes and fees for these reports are not addressed in these rules. A provider bulletin will go out to physicians telling them about the new reports and what codes to bill to be reimbursed for their services.
Comment: The ongoing documentation requirements on opioids for chronic, noncancer pain are overly burdensome. They will prevent some doctors from appropriately treating workers and/or delay appropriate treatment for workers in pain.
Response: No change was made to this WAC based on this comment. Again, the requirements listed are necessary for the department to ensure that the treatment of chronic, noncancer pain with opioids is proper and necessary, as defined in WAC 296-20-01002. Further, the documentation requirements are consistent with recommendations contained in the Department of Health Guidelines for Management of Pain (see, for example, Section F, Guidelines for Assessment and Documentation in Non-Cancer Pain; and Section G, Patient Responsibilities).
The main concern in terms of this WAC seems to be with the form, not with the rule. Feedback has been that the draft department form developed to document pain and function is too long and focuses too much on return to work. This form has recently been shortened to include only that information absolutely necessary to adjudicate claims. In addition, the revised form focuses on documenting improvement of function in daily living activities as well as return to work activities.
Comment: Documentation of functional improvement should be objective and measurable.
Response: No change was made based on this suggestion. Estimate of functional improvement may include information that is self-reported, such as patient responses to validated health surveys, or from another observer, such as the physician on examination or a physical therapist through a physical capacities evaluation.
Comment: How often is this report required?
Response: Ongoing documentation is already required at least every sixty days. See the reference sixty day reports in WAC 296-20-06101. Language was added in this section to make this more clear. See below.
Comment: Are two reports required for ongoing treatment with opioids? Documentation and a form are referenced in both WAC 296-20-03021 and 296-20-03022.
Response: Only one form is required. The sentence referring to the department form was moved to WAC 296-20-03021 to make this more clear. See below.
Change to the Proposed Rule: In addition to the general documentation required by the department or self-insurer, the attending physician must submit the following information at least every sixty days when treating with opioids:
| • | Documentation of drug screenings, consultations, and all other treatment trials; |
| • | Documentation of outcomes and responses, including pain intensity and functional levels; and |
| • | Any modifications to the treatment plan. |
WAC 296-20-03022 How long will the department or self-insurer continue to pay for opioids to treat chronic, noncancer pain?
Comment: What does substantial mean? Substantial may mean different things for different patients. Take out the word "substantial"?
Response: No change was made based on this suggestion. It is difficult to give a definition of "substantial" that would be meaningful for all types of injuries in all situations. That is why "substantial" is not defined here. On the other hand, there has to be some level of improvement above and beyond the fluctuations in levels of pain and function that occurs when a worker is fixed and stable. What "substantial" improvement means should be evident for individual cases.
Comment: These rules should allow for ongoing treatment with opioid medications for maintenance care and on closed claims.
Response: This suggestion has not been incorporated into the final rules. Although it may be medically appropriate to prescribe opioids to treat chronic pain for an extended period of time, the Industrial Insurance Act allow the department to pay for medical treatment only until the accepted condition becomes fixed and stable. This means that maintenance treatment, treatment solely to relieve symptoms or discomfort, and treatment on closed claims are not payable. Any change on this issue would have to be made at the level of the RCWs and come from the legislature.
Comment: It is not clear when payment for opioids stops.
Response: The two bullets were rewritten to make this more clear. The insurer will continue to pay for opioids when there is substantial reduction in pain (even if the level of pain plateaus) as long as the patient continues to improve functionally. See below.
Change to the Proposed Rule: The department of or
self-insurer will continue to pay for treatment with opioids so
long as the physician documents:
| • | Substantial reduction of the patient's pain intensity; and |
| • | Continuing s |
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 an opioid trial without documentation of
substantial improvement is presumed to be not proper and
necessary.
WAC 296-20-03023 When may the department or self-insurer deny payment of opioid medications used to treat chronic, noncancer pain?
Comment: Will the physician be denied reimbursement due to patient misconduct? The last sentence referring to possible sanctions in WAC 296-20-015 suggests that is the case. Please clarify.
Response: This section refers to denial of payment for the medication itself, not physician services. The reference to WAC 296-20-015 was deleted.
Change to the Proposed Rule: 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. |
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 15, Amended 1, Repealed 1.
Number of Sections Adopted on the Agency's Own Initiative: New 15, Amended 1, Repealed 1.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 15, Amended 1, Repealed 1.
Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 15, Amended 1, Repealed 1. Effective Date of Rule: January 20, 2000.
December 7, 1999
Gary Moore
Director
OTS-3364.4
AMENDATORY SECTION(Amending WSR 93-16-072, filed 8/1/93,
effective 9/1/93)
WAC 296-20-030
Treatment not requiring authorization for
accepted conditions.
(1) A maximum of twenty office calls for the treatment of the industrial condition, during the first sixty days, following injury. Subsequent office calls must be authorized. Reports of treatment rendered must be filed at sixty day intervals to include number of office visits to date. See chapter 296-20 WAC and department policies for report requirements and further information.
(2) Initial diagnostic x-rays necessary for evaluation and treatment of the industrial injury or condition. See WAC 296-20-121 for further information.
(3) The first twelve physical therapy treatments as provided by chapters 296-21, 296-23, and 296-23A WAC, upon consultation by the attending doctor or under his direct supervision. Additional physical therapy treatment must be authorized and the request substantiated by evidence of improvement. In no case will the department or self-insurer pay for inpatient hospitalization of a claimant to receive physical therapy treatment only. USE OF DIAPULSE, THERMATIC (standard model only), SPECTROWAVE AND SUPERPULSE MACHINES AND IONTOPHORESIS IS NOT AUTHORIZED FOR WORKERS ENTITLED TO BENEFITS UNDER THE INDUSTRIAL INSURANCE ACT.
(4) Routine laboratory studies reasonably necessary for diagnosis and/or treatment of the industrial condition. Other special laboratory studies require authorization.
(5) Routine standard treatment measures rendered on an emergency basis or in connection with minor injuries not otherwise requiring authorization.
(6) Consultation with specialist when indicated. See WAC 296-20-051 for consultation guidelines.
(7) ((Nonscheduled drugs and medications during the acute
phase of treatment for the industrial injury or condition.
(8) Scheduled drugs and other medications known to be addictive, habit forming or dependency inducing may be prescribed in quantities sufficient for treatment for a maximum of twenty-one days. If drug therapy extends beyond thirty days, see WAC 296-20-03003 regarding management.
(9) Injectable scheduled and other drugs known to be addictive, habit forming, or dependency inducing may be provided only on an in-patient basis. Hospital admission for administration of drugs for relief of chronic pain only will not be allowed.
(10))) Diagnostic or therapeutic nerve blocks. See WAC 296-20-03001 for restrictions.
(((11))) (8) Intra-articular injections. See WAC 296-20-03001 for restrictions.
(((12))) (9) Myelogram if prior to emergency surgery.
[Statutory Authority: RCW 51.04.020, 51.04.030 and 1993 c 159. 93-16-072, § 296-20-030, filed 8/1/93, effective 9/1/93. Statutory Authority: RCW 51.04.020(4) and 51.04.030. 86-06-032 (Order 86-19), § 296-20-030, filed 2/28/86, effective 4/1/86. Statutory Authority: RCW 51.04.020(4), 51.04.030, and 51.16.120(3). 81-24-041 (Order 81-28), § 296-20-030, filed 11/30/81, effective 1/1/82; 81-01-100 (Order 80-29), § 296-20-030, filed 12/23/80, effective 3/1/81; Order 76-34, § 296-20-030, filed 11/24/76, effective 1/1/77; Order 75-39, § 296-20-030, filed 11/28/75, effective 1/1/76; Order 74-7, § 296-20-030, filed 1/30/74; Order 71-6, § 296-20-030, filed 6/1/71; Order 70-12, § 296-20-030, filed 12/1/70, effective 1/1/71; Order 68-7, § 296-20-030, filed 11/27/68, effective 1/1/69.]
The department or self-insurer pays for drugs that are deemed proper and necessary to treat the industrial injury or occupational disease accepted under the claim. In general, the department will consider coverage for all FDA approved drugs for stated indications. The department or self-insurer may pay for prescriptions for off label indications when used within current medical standards and prescribed in compliance with published contraindications, precautions and warnings.
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(1) Amount dispensed. The department or self-insurer will pay for no more than a thirty-day supply of a medication dispensed at any one time.
(2) Over-the-counter drugs. Prescriptions for over-the-counter items may be paid. Special compounding fees for over-the-counter items are not payable.
(3) Generic drugs. Prescriptions are to be written for generic drugs unless the attending physician specifically indicates that substitution is not permitted. For example: The patient cannot tolerate substitution. Pharmacists are instructed to fill with generic drugs unless the attending physician specifically indicates substitution is not permitted.
(4) Prescriptions for unrelated medical conditions. The department or self-insurer may consider temporary coverage of prescriptions for conditions not related to the industrial injury when such conditions are retarding recovery. Any treatment for such conditions must have prior authorization per WAC 296-20-055.
(5) Pension cases. Once the worker is placed on a pension, the department or self-insurer may pay for only those drugs and medications authorized for continued medical treatment for conditions previously accepted by the department. Authorization for continued medical and surgical treatment is at the sole discretion of the supervisor of industrial insurance and must be authorized before the treatment is rendered. In such pension cases, the department or self-insurer cannot pay for scheduled drugs used to treat continuing pain resulting from an industrial injury or occupational disease.
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The department's outpatient drug and medication coverage decisions are contained in the department's formulary, as developed by the department in collaboration with the Washington State Medical Association's Industrial Insurance and Rehabilitation Committee.
In the formulary, drugs are listed in the following categories:
• Allowed
Drugs used routinely for treating accepted industrial injuries and occupational illnesses.
Example: Nonscheduled drugs and other medications during the acute phase of treatment for the industrial injury or condition.
• Prior authorization required
Drugs used routinely to treat conditions not normally accepted as work related injuries, drugs which are used to treat unrelated conditions retarding recovery from the accepted condition on the claim, and drugs for which less expensive alternatives exist.
Example: All drugs to treat hypertension because hypertension is not normally an accepted industrial condition.
• Denied
Drugs not normally used for treating industrial injuries or not normally dispensed by outpatient pharmacies.
Example: Most hormones, most nutritional supplements.
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Some of the drugs that are routinely denied may be covered in special circumstances. Requests for coverage under special circumstances require authorization prior to treatment. Examples of drugs that may be covered in special circumstances include:
• Drugs and medications to treat unrelated conditions when retarding recovery;
• Special treatments for unique catastrophic injuries.
The department may require written documentation to support the request.
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(1) Injectables. Prescriptions for injectable opioids or other analgesics, sedatives, antihistamines, tranquilizers, psychotropics, vitamins, minerals, food supplements, and hormones are not covered.
Exceptions: The department or self-insurer covers injectable medications under the following circumstances.
(a) Indicated injectable drugs for the following:
• Inpatients; or
• During emergency treatment of a life-threatening condition/injury; or
• During outpatient treatment of severe soft tissue injuries, burns or fractures when needed for dressing or cast changes; or
• 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, anti-migraine medications, or impotency treatment, when proper and necessary.
(2) 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.
(3) Sedative-hypnotics. During the chronic stage of an industrial injury or occupational disease, payment for scheduled sedatives and hypnotics will not be authorized.
(4) Benzodiazepines. Payment for prescriptions for benzodiazepines are limited to the following types of patients:
• Hospitalized patients;
• Claimants with an accepted psychiatric disorder for which benzodiazepines are indicated;
• Claimants with an unrelated psychiatric disorder that is retarding recovery but which the department or self-insurer has temporarily authorized treatment (see WAC 296-20-055) and for which benzodiazepines are indicated; and
• Other outpatients for not more than thirty days for the life of the claim.
(5) Cancer. When cancer or any other end-stage disease is an accepted condition, the department or self-insurer may authorize payment for any indicated scheduled drug and by any indicated route of administration.
(6) Spinal cord injuries. When a spinal cord injury is an accepted condition, the department or self-insurer may authorize payment for anti-spasticity medications by any indicated route of administration (e.g., some benzodiazepines, Baclofen). Prior authorization is required.
Note: See the department formulary for specific limitations and prior authorization requirements of other drugs.
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(1) The department or self-insurer may take any or all of the following steps when concerned about the amount or appropriateness of drugs the patient is receiving:
• Notify the attending physician of concerns regarding the medications such as drug interactions, adverse reactions, prescriptions by other providers;
• Require that the attending physician send a treatment plan addressing the drug concerns;
• Request a consultation from an appropriate specialist;
• Request that the attending physician consider reducing the prescription, and provide information on chemical dependency programs;
• Limit payment for drugs on a claim to one prescribing doctor.
(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 department or self-insurer may discontinue payment for the drug after adequate prior notification has been given to the worker, pharmacy and physician.
(3) Physician failure to reduce or terminate prescription of controlled substances, habit forming or addicting medications, or dependency inducing medications, after department or self-insurer request to do so for an injured worker may result in a transfer of the worker to another physician of the worker's choice. (See WAC 296-20-065.)
(4) Other corrective actions may be taken in accordance with WAC 296-20-015, Who may treat.
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The department or self-insurer may pay for detoxification and/or chemical dependency treatment in the following circumstances:
• The injured worker becomes dependent or toxic on medication prescribed for an accepted condition on the claim; or
• The injured worker becomes dependent or toxic due to medications prescribed for a condition retarding recovery of the accepted condition on the claim; or
• The injured worker is dependent or toxic due to medications for an unrelated condition, but that dependency or toxicity is retarding recovery of the accepted condition.
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Prescriptions must include the department authorized provider number for the prescribing physician and the physician's signature. 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. Please refer to WAC 296-20-03021 and 296-20-03022 for additional documentation requirements when treating chronic, noncancer pain.
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In general, the department or self-insured employer pays for most drugs in an inpatient hospital setting. Please see WAC 296-20-075, Hospitalization.
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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 department or self-insurer may pay for oral opioids for the treatment of chronic, noncancer pain caused by an accepted condition when that treatment is proper and necessary. See WAC 296-20-01002 for the definition of "proper and necessary" health care services.
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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 department or self-insurer in order for the department or self-insurer to pay for such treatment. The written report must include the following:
• A treatment plan with time-limited goals;
• A consideration of relevant prior medical history;
• A summary of conservative care rendered to the worker that focused on reactivation and return to work;
• A statement on why prior or alternative conservative measures may have failed or are not appropriate as sole treatment;
• A summary of any consultations that have been obtained, particularly those that have addressed factors that may be barriers to recovery;
• 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
• 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.
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In addition to the general documentation required by the department or self-insurer, the attending physician must submit the following information at least every sixty days when treating with opioids:
• Documentation of drug screenings, consultations, and all other treatment trials;
• Documentation of outcomes and responses, including pain intensity and functional levels; and
• Any modifications to the treatment plan.
The physician must use a form developed by the department, or a substantially equivalent form, to document the patient's improvement in pain intensity and functional levels. This form may be included as part of a sixty-day report.
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The department or self-insurer will continue to pay for treatment with opioids so long as the physician documents:
• Substantial reduction of the patient's pain intensity; and
• 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 improvement is presumed to be not proper and necessary.
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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.
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The department or self-insurer may pay for nonopioid medication for the treatment of chronic, noncancer pain when it is proper and necessary.
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.
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The following section of the Washington Administrative Code is repealed:
| WAC 296-20-03003 | Drugs and medication. |