WSR 12-07-066

PROPOSED RULES

DEPARTMENT OF

LABOR AND INDUSTRIES

[ Filed March 20, 2012, 8:59 a.m. ]

Original Notice.

Preproposal statement of inquiry was filed as WSR 11-20-082.

Title of Rule and Other Identifying Information: WAC 296-20-030 Treatment not requiring authorization for accepted conditions, 296-20-03001 Treatment requiring authorization, and 296-20-03002 Treatment not authorized.

Hearing Location(s): Department of Labor and Industries Headquarters, Room S117, 7273 Linderson Way S.W., Tumwater, WA 98501, on April 27, 2012, at 1 p.m.

Date of Intended Adoption: June 5, 2012.

Submit Written Comments to: Marie Manteuffel, Department of Labor and Industries (L&I), Office of the Medical Director, P.O. Box 44321, Olympia, WA 98504-4321, e-mail marie.manteuffel@lni.wa.gov, fax (360) 902-6315, received no later than 5:00 p.m., May 4, 2012.

Assistance for Persons with Disabilities: Contact office of information and assistance by April 13, 2012, TTY (360) 902-5797.

Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The purpose of this proposed language is to amend current WAC language to be consistent with health technology clinical committee (HTCC) decisions. On June 17, 2011, the HTCC adopted a final determination on spinal injections that conflicts with current chapter 296-20 WAC, Medical aid rules. References to transcutaneous, interferential, and percutaneous nerve stimulators will also be removed per a prior HTCC determination in 2010. Finally, HTCC decisions related to lumbar fusion in 2007 have been implemented, but rule language related to discograms and structured intensive multidisciplinary programs (SIMPs) also needs to be amended.

The effect of these changes will be better alignment of coverage decisions with HTCC determinations.

Reasons Supporting Proposal: The department is required to implement coverage determinations of the HTCC per RCW 70.14.110.

Statutory Authority for Adoption: RCW 70.14.110, 51.04.020, and 51.04.030.

Statute Being Implemented: RCW 70.14.110.

Rule is not necessitated by federal law, federal or state court decision.

Name of Proponent: The department of labor and industries, governmental.

Name of Agency Personnel Responsible for Drafting: Marie Manteuffel, Medical Program Specialist, Office of the Medical Director, (360) 902-5026; Implementation: Gary Franklin, Medical Director, (360) 902-5020; and Enforcement: Beth Dupre, Assistant Director for Insurance Services, (360) 902-4209.

No small business economic impact statement has been prepared under chapter 19.85 RCW. The department did not prepare a small business economic impact statement because it determined that the proposed rules will not impose more than minor costs on businesses in an industry, nor will it have a disproportionate impact on small businesses.

A cost-benefit analysis is required under RCW 34.05.328. A preliminary cost-benefit analysis may be obtained by contacting Marie Manteuffel, Department of Labor and Industries, Office of the Medical Director, P.O. Box 44321, Olympia, WA 98504-4321, phone (360) 902-5026, fax (360) 902-6315, e-mail marie.manteuffel@lni.wa.gov.

March 20, 2012

Judy Schurke

Director

OTS-4644.1


AMENDATORY SECTION(Amending WSR 00-01-040, filed 12/7/99, effective 1/20/00)

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) ((Diagnostic or therapeutic nerve blocks. See WAC 296-20-03001 for restrictions.

(8) Intra-articular injections. See WAC 296-20-03001 for restrictions.

(9))) Myelogram if prior to emergency surgery.

[Statutory Authority: RCW 51.04.020 and 51.04.030. 00-01-040, 296-20-030, filed 12/7/99, effective 1/20/00. 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.]


AMENDATORY SECTION(Amending WSR 08-24-047, filed 11/25/08, effective 12/26/08)

WAC 296-20-03001   Treatment requiring authorization.   Certain treatment procedures require authorization by the department or self-insurer. Requests for authorization must include a statement of: The condition(s) diagnosed; ICD-9-CM codes; their relationship, if any, to the industrial injury/exposure; an outline of the proposed treatment program, its length and components, procedure codes, and expected prognosis; and an estimate of when treatment would be concluded and condition stable.

(1) Office calls in excess of the first twenty visits or sixty days whichever occurs first.

(2) The department may designate those inpatient hospital admissions that require prior authorization.

(3) X ray and radium therapy.

(4) Diagnostic studies other than routine X-ray and blood or urinalysis laboratory studies.

(5) Myelogram ((and discogram)) in nonemergent cases.

(6) Physical therapy treatment beyond initial twelve treatments as outlined in chapters 296-21, 296-23, and 296-23A WAC.

(7) Diagnostic or therapeutic injections((. Epidural or caudal injection of substances other than anesthetic or contrast solution will be authorized under the following conditions only:

(a) When the worker has experienced acute low back pain or acute exacerbation of chronic low back pain of no more than six months duration.

(b) The worker will receive no more than three injections in an initial thirty-day treatment period, followed by a thirty-day evaluation period. If significant pain relief is demonstrated one additional series of three injections will be authorized. No more than six injections will be authorized per acute episode.)) that include, but are not limited to:

(a) Therapeutic subarachnoid, epidural, or caudal injections for chronic pain;

(b) Diagnostic facet injections;

(c) Sacroiliac joint injections for chronic pain;

(d) Intra-muscular and trigger point injections of steroids and other nonscheduled medications are limited to three injections per patient. The attending doctor must submit justification for an additional three injections if indicated with a maximum of six injections to be authorized for any one patient.

Refer to fee schedule payment policies and coverage decisions for authorization criteria.

(8) Home nursing, attendant services or convalescent center care must be authorized per provisions outlined in WAC 296-20-091 or 296-23-246.

(9) Provision of prosthetics, orthotics, surgical appliances, special equipment for home or transportation vehicle; custom made shoes for ankle/foot injuries resulting in permanent deformity or malfunction of a foot; ((TNS units;)) masking devices; hearing aids; etc., must be authorized in advance as per WAC 296-20-1101 and 296-20-1102.

(10) Biofeedback program; structured intensive multidisciplinary pain programs (SIMPs); pain clinic; weight loss program; psychotherapy; rehabilitation programs; and other programs designed to treat special problems must be authorized in advance. Refer to the department's medical aid rules and fee schedules for details.

(11) Prescription or injection of vitamins for specific therapeutic treatment of the industrial condition(s) when the attending doctor can demonstrate that published clinical studies indicate vitamin therapy is the treatment of choice for the condition. Authorization for this treatment will require presentation of facts to and review by department medical consultant.

(12) ((Injections of anesthetic and/or anti-inflammatory agents into the vertebral facet joints will be authorized to qualified specialists in orthopedics, neurology, and anesthesia, or other physicians who can demonstrate expertise in the procedure, AND who can provide certification their hospital privileges include the procedure requested under the following conditions:

(a) Rationale for procedure, treatment plan, and request for authorization must be presented in writing to the department or self-insurer.

(b) Procedure must be performed in an accredited hospital under radiographic control.

(c) Not more than four facet injection procedures will be authorized in any one patient.

(13))) The long term prescription of medication under the specific conditions and circumstances in (a) and (b) of this subsection are considered corrective therapy rather than palliative treatment and approval in advance must be obtained.

(a) Nonsteroidal anti-inflammatory agents for the treatment of degenerative joint conditions aggravated by occupational injury.

(b) Anticonvulsive agents for the treatment of seizure disorders caused by trauma.

(((14) Intra-muscular and trigger point injections of steroids and other nonscheduled medications are limited to three injections per patient. The attending doctor must submit justification for an additional three injections if indicated with a maximum of six injections to be authorized for any one patient.

(15))) (13) The department may designate those diagnostic and surgical procedures which can be performed in other than a hospital inpatient setting. Where a worker has a medical condition which necessitates a hospital admission, prior approval of the department or self-insurer must be obtained.

[Statutory Authority: RCW 51.04.020, 51.04.030, and Title 51 RCW. 08-24-047, 296-20-03001, filed 11/25/08, effective 12/26/08. Statutory Authority: RCW 51.04.020, 51.04.030, 51.32.060, 51.32.072, and 7.68.070. 01-18-041, 296-20-03001, filed 8/29/01, effective 10/1/01. Statutory Authority: RCW 51.04.020, 51.04.030 and 1993 c 159. 93-16-072, 296-20-03001, filed 8/1/93, effective 9/1/93. Statutory Authority: RCW 51.04.020(4) and 51.04.030. 90-04-057, 296-20-03001, filed 2/2/90, effective 3/5/90; 86-20-074 (Order 86-36), 296-20-03001, filed 10/1/86, effective 11/1/86; 86-06-032 (Order 86-19), 296-20-03001, filed 2/28/86, effective 4/1/86; 83-16-066 (Order 83-23), 296-20-03001, filed 8/2/83. Statutory Authority: RCW 51.04.020(4), 51.04.030, and 51.16.120(3). 81-24-041 (Order 81-28), 296-20-03001, filed 11/30/81, effective 1/1/82; 81-01-100 (Order 80-29), 296-20-03001, filed 12/23/80, effective 3/1/81. Statutory Authority: RCW 51.04.030 and 51.16.035. 79-12-086 (Order 79-18), 296-20-03001, filed 11/30/79, effective 1/1/80; Order 76-34, 296-20-03001, filed 11/24/76, effective 1/1/77.]


AMENDATORY SECTION(Amending WSR 09-20-040, filed 9/30/09, effective 11/1/09)

WAC 296-20-03002   Treatment not authorized.   The department or self-insurer will not allow nor pay for following treatment:

(1) Use of diapulse, thermatic (standard model only), spectrowave and superpulse machines on workers entitled to benefits under the Industrial Insurance Act.

(2) Iontophoresis; prolotherapy; acupuncture; injections of colchicine; injections of fibrosing or sclerosing agents; and injections of substances other than anesthetic or contrast into the subarachnoid space (intra-thecal injections).

(3) Treatment to improve or maintain general health (i.e., prescriptions and/or injection of vitamins or referrals to special programs such as health spas, swim programs, exercise programs, athletic-fitness clubs, diet programs, social counseling).

(4) Continued treatment beyond stabilization of the industrial condition(s), i.e., maintenance care, except where necessary to monitor prescription of medication necessary to maintain stabilization i.e., anti-convulsive, anti-spasmodic, etc.

(5) After consultation and advice to the department or self-insurer, any treatment measure deemed to be dangerous or inappropriate for the injured worker in question.

(6) Treatment measures of an unusual, controversial, obsolete, or experimental nature (see WAC 296-20-045). Under certain conditions, treatment in this category may be approved by the department or self-insurer. Approval must be obtained prior to treatment. Requests must contain a description of the treatment, reason for the request with benefits and results expected.

(7) Therapeutic medial branch block injections, therapeutic intradiscal injections, and therapeutic facet injections.

(8) Transcutaneous, interferential, and percutaneous nerve stimulators used in the home setting, and all associated supplies and equipment.

[Statutory Authority: RCW 70.14.120, 51.04.020, 51.04.030. 09-20-040, 296-20-03002, filed 9/30/09, effective 11/1/09. Statutory Authority: RCW 51.04.020, 51.04.030. 06-15-110, 296-20-03002, filed 7/18/06, effective 8/18/06. Statutory Authority: RCW 51.04.020(4) and 51.04.030. 86-06-032 (Order 86-19), 296-20-03002, filed 2/28/86, effective 4/1/86; 83-16-066 (Order 83-23), 296-20-03002, filed 8/2/83. Statutory Authority: RCW 51.04.020(4), 51.04.030, and 51.16.120(3). 81-24-041 (Order 81-28), 296-20-03002, filed 11/30/81, effective 1/1/82; 81-01-100 (Order 80-29), 296-20-03002, filed 12/23/80, effective 3/1/81; Order 76-34, 296-20-03002, filed 11/24/76, effective 1/1/77.]

Washington State Code Reviser's Office