WSR 05-03-089

INTERPRETIVE AND POLICY STATEMENT

DEPARTMENT OF

LABOR AND INDUSTRIES

[ Filed January 18, 2005, 10:07 a.m. ]

In accordance with RCW 34.05.230(12), enclosed are the policy and interpretive statements issued by the department for December 2004.

If you have any questions or need additional information, please call Carmen Moore at (360) 902-4206.


POLICY AND INTERPRETIVE STATEMENTS

WISHA


1. WISHA Regional Directive (WRD) 27.20, Traffic Control and Flagging Operations

This directive provides guidance to WISHA enforcement and consultation staff when evaluating work zones where traffic control or flaggers are used. It will remain in place indefinitely, and replaces all other instructions on this issue, whether formal or informal.

This new policy was established December 30, 2004.

Contact Marcia Benn, Mailstop 44648, phone (360) 902-5503.

Insurance Services


1. Program: Office of the Medical Director, Crime Victims, State Fund Claims Administration and Self-Insurance

Provider Bulletin 04-11: Hearing Aid Services and Devices Reimbursement Policies and Rates

Effective September 1, 2004, this Provider Bulletin consolidates and replaces:

Provider Bulletin 01-09 and 02-09, and

The hearing aid related information in Provider Updates: 99-01 and 00-01

The following policies and requirements apply to all hearing aid services and devices, except those listed in the Physicians' Current Procedural Terminology (CPT).

Self-insured companies who have entered into contracts for purchasing hearing aid related services and devices may continue to use them. Self-insured companies who do not have hearing aid purchasing contracts must follow the department's maximum fee schedule and purchasing policies for all hearing aid services and devices listed in this bulletin.

Which policies have changed?

Digital hearing aids may be covered, if that technology best addresses a worker's needs.

New worker information and restocking forms have been developed, see appendix.

Advertising limits are explained.

Professional fees.

Policy or program information covered in the Provider Bulletin includes:

Authorization and payment policies

Advertising limits

Types of hearing aids authorized

Hearing aid quality

Testing

Trial period

Warranties

Repairs and batteries

Replacement

Documentation and record-keeping requirements

Billing procedures

Information about a specific claim

Fee schedules

Appendix: New timelines for filing occupational hearing loss.

This new policy was effective July 2004.

Contact Grace Wang, Mailstop 44321, phone (360) 902-5227.


2. Program: Office of the Medical Director, Crime Victims, State Fund Claims Administration and Self-Insurance

Provider Bulletin 04-12: Review Criteria for Thoracic Outlet Syndrome Surgery (TOS)

This Provider Bulletin replaces PB 95-04 and becomes effective September 1, 2004.

Provider Bulletin 04-06 describes policies currently in effect for state fund and self-insurance claims in all locations:

The purpose of this Provider Bulletin is to notify providers that all inpatient or outpatient surgery for vascular or neurogenic TOS or for entrapment of the brachial plexus will require prior approval and utilization review (UR) for state fund claims.

The Provider Bulletin includes an update in CPT codes that require prior approval and UR for state fund claims, the criteria for the electrodiagnostic diagnosis of unilateral neurogenic TOS, and the review criteria for TOS surgery.

This new policy is effective August 2004.

Contact Grace Wang, Mailstop 44321, phone (360) 902-5227.


3. Program: Office of the Medical Director, Crime Victims, State Fund Claims Administration and Self-Insurance

Provider Bulletin 04-13: Coverage Decision (May 2004 to September 2004)

This provider bulletin describes policies currently in effect for state fund in all locations:

&lhlsqbul; Noncoverage of low level laser therapy (LLLT).

LLLT is not a covered therapy because it is considered investigational. Published literature has not substantially shown effectiveness of LLLT.

&lhlsqbul; Noncoverage of autologous blood injections (replaces coverage decision memos dated June 25, 2004).

Autologous blood injection/patch therapy is not a covered therapy at this time for lateral epicondylitis or any other indication. This therapy is considered experimental to a lack of published literature indicating safety and effectiveness.

Epidural blood patches used for spinal leaks are a different procedure and remain covered for that purpose.

&lhlsqbul; Noncoverage of tinnitus retraining therapy (TRT) (replaces coverage decision memos dated June 25, 2004).

Tinnitus retraining therapy is not a covered therapy because it is considered investigational and controversial due to the lack of evidence addressing effectiveness for tinnitus.

This bulletin also describes policies currently in effect for state fund and self-insurers in all locations:

&lhlsqbul; Coverage of powered traction devices (updates PB 00-09 and replaces coverage decision memos dated June 25, 2004).

Powered traction is a covered therapy. This decision applies to all FDA approved powered traction devices.

When powered traction is a proper and necessary treatment, the department or self-insured employer may pay for powered traction therapy administered by a licensed practitioner.

Only one unit of this code will be paid per visit, regardless of the length of time traction is applied.

The department will not pay any additional cost when powered traction devices are used because published literature has not substantially shown whether powered traction devices are more effective than other forms of traction, other conservative treatments, or surgery.

&lhlsqbul; Coverage of hyaluronic acid (HA) (updates PB 98-10).

HA injections are indicated only for osteoarthritis of the knee. When osteoarthritis is the accepted condition or is retarding recovery from an accepted condition, one course of HA may be considered medically necessary. Prior authorization is required for HA injections.

This bulletin describes a policy effective November 1, 2004 for state fund and self-insurers in all locations:

&lhlsqbul; Coverage of Epidural Adhesiolysis.

Epidural Adhesiolysis conducted with the 1-day protocol may be authorized for patients who meet all of the following criteria:

> The injured worker has experienced acute low back pain or acute exacerbation of chronic low back pain of no more than six months duration.

> The physician intends to conduct the adhesiolysis in order to administer drugs in immediate proximity to a nerve.

> The physician documents strong suspicion of adhesions blocking access to the nerve.

> Adhesions blocking access to the nerve have been identified by:

Gallium MRI, or

Fluoroscopy during epidural steroid injections.

Epidural Adhesiolysis conducted with the 1-day protocol requires prior authorization.

Adhesiolysis conducted with the 3-day protocol and endoscopic adhesiolysis are not covered procedures at this time.

This new policy was issued August 2004.

Contact Grace Wang, Mailstop 44321, phone (360) 902-5227.


4. Program: Office of the Medical Director, Crime Victims, State Fund Claims Administration and Self-Insurance

Provider Bulletin 04-15: Chronic Pain Management Program

Provider Bulletin 04-15 explains revisions the department recently made to its policies concerning the authorization and payment of chronic pain management programs.

This bulletin replaces Provider Bulletin 93-02.

Specifically, the revisions to the chronic pain management program include:

Eliminating the current chronic pain management program contracts,

Establishing an all inclusive, phase-based, per diem fee schedule,

Establishing a per diem fee schedule for inpatient room and board services, and

Authorizing the extension of the treatment phase using specific criteria.

In addition to these revisions of the chronic pain management program, disability prevention evaluations by chronic pain management programs will be eliminated.

What is changing?

Since 1987, the department has authorized and paid for chronic pain management programs by contract. Effective February 1, 2005, these contracts will be eliminated and replaced by a fee schedule payable to any chronic pain management program meeting the provider requirements. This fee schedule will be all-inclusive, paid by chronic pain management phase, and is based on a daily rate.

This bulletin provides new maximum allowable fees and billing codes for chronic pain management programs. These fees will be effective for dates of service on or after February 1, 2005.

Policy or program information covered in the Provider Bulletin includes:

When should an injured worker be referred for a chronic pain management program evaluation?

What are the chronic pain management program phases and the fee schedule?

What is a Return to Work Action Plan?

Who is involved when a return to work action plan is developed and implemented?

What is the fee schedule for inpatient room and board costs?

What if the injured worker needs more treatment than is permitted by the limit established in the fee schedule?

What are the criteria for extending the treatment phase?

Who is eligible to provide chronic pain management program services to injured workers?

What if a Commission on Accreditation of Rehabilitation Facilities (CARF) accredited provider is not reasonably available for injured workers who have moved out of Washington State?

If an injured worker does not complete a full day of treatment or follow-up, how do I bill for those services?

Why are Disability Prevention Evaluations being discontinued?

Where can I find out any additional information about the chronic pain management program or disability prevention evaluations?

This policy was issued October 2004.

Contact Grace Wang, Mailstop 44321, phone (360) 902-5227.


5. Program: Office of the Medical Director, Crime Victims, State Fund Claims Administration and Self-Insurance

Provider Bulletin 04-16: Nursing Home, Transitional Care Unit, Adult Family Home and Boarding Home Payment System

The bulletin explains the new L&I facilities payment system, including policies and fees, for residential care facilities.

This bulletin applies to state fund claims when authorization is requested for services to be provided in residential care facilities on or after January 1, 2005.

For information regarding self-insurer requirements contact the self-insurer directly.

Policy or program information covered in the Provider Bulletin includes:

What types of services are being affected?

Who may provide the services?

What types of services does the department cover?

What services are included in the new system?

How was the Nursing Home and Transitional Care Unit fee schedule developed?

How do you bill for pharmaceuticals and Durable Medical Equipment?

How do residential care facilities receive authorization?

What if the care needs of the injured worker in a Nursing Home or Transitional Care Unit change?

Will the department review residential care services?

How will the payment system changes affect injured workers and providers?

What are the requirements for billing, payment and record keeping?

Nursing Home and Transitional Care Unit Fee Schedule

Adult Family Home and Boarding Home Fee Schedule

Where is more information available?

This policy was issued October 2004.

Contact Grace Wang, Mailstop 44321, phone (360) 902-5227.


6. Program: Office of the Medical Director, Crime Victims, State Fund Claims Administration and Self-Insurance

Provider Bulletin 04-17: Spinal Cord Stimulation

This Provider Bulletin announces a pilot study entitled "Spinal Cord Stimulators (SCS) for Injured Workers with Chronic Low Back and Leg Pain after Lumbar Surgery" that pertains to state fund claims in all locations. This bulletin is currently in effect.

SCS is a noncovered procedure for State Fund claimants. However, the department will cover SCS for state fund claimants if performed as part of the SCS pilot study conducted by the University of Washington.

The study is entitled, "Spinal Cord Stimulators (SCS) for Injured Workers with Chronic Low Back and Leg Pain after Lumbar Surgery." Payment authorization will be contingent upon the patient consenting to participate in the study, meeting the study inclusion criteria, and completing the baseline assessment.

The study aims to observe SCS outcomes in routine practice. Therefore, individual physicians in the community will conduct the implantation procedure and provide follow-up care. Individual physicians will also choose the length of the trial SCS period, the type of SCS device, and the type of pulse generator.

The study aims to recruit fifty injured workers to undergo a trial of SCS. The study also aims to recruit fifty patients each to two comparison groups. The comparison groups will comprise injured workers with chronic LBP who meet inclusion and exclusion criteria for SCS, but who have not been offered SCS by their physician. The first comparison group will receive usual care for their symptoms.

The second comparison group will receive treatments at multidisciplinary pain clinics.

This policy was restated November 2004.

Contact Gary Franklin, Mailstop 44321, phone (360) 902-5020.


7. Program: State Fund Claims Administration

Guideline - Job offers, 'odd lot' employment, temporary and light-duty jobs

This memorandum provides:

Guidelines regarding the payment of time-loss compensation benefits when the employer of record offers a light-duty or permanent job.

Characteristics of a bona fide job offer.

This new policy was issued November 19, 2004.

Contact Valerie Grimm, Mailstop 4208, phone (360) 902-5005.

Carmen Moore

Rules Coordinator

Washington State Code Reviser's Office