Chymopapain injections may be authorized in the treatment of lumbar disc disease under the following limitations and criteria:

(1) Only physicians (a) who routinely care for patients with herniated lumbar intervertebral discs, (b) who are qualified by training and experience to diagnose lumbar disc disease and to perform laminectomy, discectomy or other spinal procedures, (c) who have received specialized training in chemonucleolysis, may administer the procedure for industrial injured workers covered under state industrial insurance fund or self-insurance.

(2) Preadministration work-up shall include but is not limited to (a) a concurring opinion from a physician familiar with the procedure and qualified by training and experience to diagnose and treat lumbar disc disease, (b) diagnostic studies indicative of level of disc herniation i.e., myelogram, a high resolution CT scan, discogram, etc., (c) other diagnostic studies including sedimentation rate (anaphylaxis has occurred primarily in females with sedimentation rates in excess of 20 mm per hour) as indicated for the individual patient.

(3) Procedure will be authorized (a) one time only in the treatment life of any given patient, (b) maximum of two levels per patient (Generally only one level will be authorized. Indications for a second level are infrequent. However, authorization may be granted if diagnostic studies and/or concurring opinion so indicates.), (c) only for patients who have had no previous lumbar surgery at that level.

(4) Procedure must be carried out in hospital setting under radiographic or fluoroscopic control, with a permanent X-ray record maintained.

(5) Prior authorization from the department or the self-insurer must be obtained before procedure is scheduled.

(6) These rules were formulated based upon the recommendations of the Federal Food and Drug Administration, the drug manufacturer, and the industrial insurance committee of the Washington state medical association.