Original Notice.

Preproposal statement of inquiry was filed as WSR 99-08-040 and 99-08-041.

Title of Rule: Amending WAC 388-501-0165 Approval process for medical equipment and medical or dental services and 388-501-0160 Exception to rule--Request for a noncovered medical or dental service; and repealing WAC 388-200-1160 Notification of exception to rule request and decision.

Purpose: To rewrite and clarify the approval process for MAA services or equipment that require prior approval, and the process for requesting an exception to rule for medical or dental services or equipment.

Statutory Authority for Adoption: RCW 74.08.090.

Statute Being Implemented: RCW 74.08.090.

Summary: These rules are being rewritten to comply with the principles in the Governor's Executive Order 97-02, and to provide clear directions for requesting prior authorization for a covered medical or dental service or equipment, and for requesting a noncovered service or equipment.

Reasons Supporting Proposal: To comply with the Governor's Executive Order 97-02.

Name of Agency Personnel Responsible for Drafting: Leslie Saeger, P.O. Box 45530, Olympia, WA 98504, (360) 664-2315; Implementation and Enforcement: Sharon Morrison, P.O. Box 45506, Olympia, WA 98504, (360) 586-5398.

Name of Proponent: Department of Social and Health Services, Medical Assistance Administration, governmental.

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

Explanation of Rule, its Purpose, and Anticipated Effects: The rule is being rewritten to clarify language and department policy. No change in the processes currently used has been made.

Proposal Changes the Following Existing Rules: WAC 388-200-1160 is proposed for repeal; and WAC 388-501-0160 and 388-501-0165 are being amended.

No small business economic impact statement has been prepared under chapter 19.85 RCW. The department has analyzed the proposed amendments and repeal and concludes that no new costs will be imposed on small business affected by them.

RCW 34.05.328 does not apply to this rule adoption. These amendments do not meet the definition of a significant legislative rule; the amendments do not change the effect of current rules.

Hearing Location: Lacey Government Center (behind Tokyo Bento Restaurant), 1009 College Street S.E., Room 104-B, Lacey, WA 98503, on November 9, 1999, at 10:00 a.m.

Assistance for Persons with Disabilities: Contact Paige Wall by October 26, 1999, phone (360) 664-6094, TTY (360) 664-6178, e-mail wallpg@dshs.wa.gov.

Submit Written Comments to: Identify WAC Numbers, Paige Wall, Rules Coordinator, Rules and Policies Assistance Unit, P.O. Box 45850, Olympia, WA 98504-5850, fax (360) 664-6185, by November 9, 1999.

Date of Intended Adoption: November 10, 1999.

September 30, 1999

Marie Myerchin-Redifer, Manager

Rules and Policies Assistance Unit

This section applies to fee for service (FFS) requests for covered medical equipment and medical or dental services that require prior authorization.

(1) ((The department shall evaluate the request for medical services as described under chapter 388-86 WAC.

(2) The department shall base a decision to approve or deny a service on obtainable evidence that establishes whether the service is "medically necessary" as defined under WAC 388-500-0005.

(a) In each case, the department shall:

(i) Make an individualized decision whether a requested service is "medically necessary"; and

(ii) Base such decision only on information contained in the client's file.

(b) The evidence must be sufficient to determine that the requested service is or is not "medically necessary," and may include:

(i) A physiological description of the disease, injury, impairment, or other ailment;

(ii) Pertinent laboratory findings;

(iii) X-ray reports;

(iv) Patient profiles; and

(v) Other objective medical information, including but not limited to medically acceptable clinical findings and diagnoses resulting from physical or mental examinations.

(3) In deciding to approve or deny a durable medical equipment or prosthetic device request, the department shall give substantial weight to objective medical information, and conclusions based thereon, from an examining physician responsible for the client's diagnosis or treatment or both when:

(a) There is an uncontradicted and adequately substantiated conclusion of an examining physician that the requested service is "medically necessary." The department shall accept the examining physician's conclusion unless the department presents specific detailed reasons for rejecting that conclusion that are consistent with sound medical practice and supported by objective medical information in the client's file.

(b) Two or more examining physicians provide conflicting medical information on conclusions about whether the requested durable medical equipment or a prosthetic device is "medically necessary," the department may conclude the durable medical equipment or a prosthetic device is not "medically necessary" only if the department enumerates specific reasons for its conclusion that are supported by objective medical information in the client's file.

(4) The department shall deny a requested service when the service is:

(a) Not medically necessary as defined under WAC 388-500-0005;

(b) Generally regarded by the medical profession as experimental in nature or as unacceptable treatment; or

(c) Unless the client demonstrates through sufficient objective clinical evidence the existence of particular circumstances rendering the requested service medically necessary; or

(d) Not a covered service.

(5) The department shall:

(a) Approve or deny all requests for medical services within fifteen days of the receipt of the request; or

(b) Return a request to the requesting provider when the information submitted is insufficient for a determination of medical necessity and the requested service is a covered service.  The department shall make a request for justifying additional information from the requesting provider within fifteen calendar days of the original receipt.  If additional information is:

(i) Not received by the department within thirty days of the date requested, the department shall deny the original request within five days after the thirty-day period on the basis of insufficient justification of medical necessity;

(ii) Received by the department, the department shall make a final determination on the request within five working days of the receipt of the additional information.

(c) Send to the client a copy of the request for additional information justifying medical necessity for durable medical equipment or a prosthetic device)) MAA evaluates requests on an individual basis, and bases the decision to approve or deny on submitted and obtainable evidence. Requests are approved when MAA determines that the service or equipment is medically necessary as defined in WAC 388-500-0005 or dentally necessary as defined in WAC 388-535-1050.

(2) The examining physician/dentist responsible for the client's diagnosis and/or treatment must submit specific evidence sufficient to determine if the request is medically/dentally necessary. Such evidence may include, but is not limited to:

(a) A client specific physiological description of the disease, injury, impairment, or other ailment;

(b) Pertinent laboratory findings;

(c) X-ray and/or imaging reports;

(d) Individual patient records pertinent to the case or request;

(e) Photographs and/or videos when requested by MAA;

(f) Dental x-rays; and

(g) Objective medical/dental information, including but not limited to medically/dentally acceptable clinical findings and diagnoses resulting from physical or mental examinations.

(3) MAA gives substantial weight to objective medical/dental information and resulting conclusions from an examining physician/dentist responsible for the client's diagnosis and/or treatment.

(a) MAA accepts the examining physician's/dentist's uncontradicted and adequately substantiated conclusion with respect to medical/dental necessity, unless MAA presents specific detailed reasons for rejecting that conclusion. MAA's reasons will be consistent with sound medical/dental practice and supported by objective medical/dental information in the client's file.

(b) If two or more examining physicians/dentists provide conflicting medical/dental information or conclusions about medical/dental necessity for the request under review, MAA will use all information submitted to reach a decision. If MAA concludes the request is not medically/dentally necessary, MAA will enumerate specific reasons, supported by objective medical/dental information in the client's file, for that decision.

(4) MAA denies a request when the service or equipment:

(a) Is determined not to be medically/dentally necessary;

(b) Is noncovered; or

(c) Is not generally considered as acceptable treatment by the medical/dental profession based on the community standard of practice, or is experimental in nature. However, MAA may approve such a request if the provider submits sufficient objective clinical evidence demonstrating that a client's particular circumstances make the request medically/dentally necessary.

(5) Within fifteen calendar days of receiving a request:

(a) MAA approves or denies the request; or

(b) Requests additional justifying information from the prescribing physician, dentist, specialty therapist, and/or service vendor if the documentation submitted is insufficient to reasonably determine medical or dental necessity. Examples of information that MAA may request are shown in subsection (2) of this section. MAA sends a copy of the request to the client at the same time.

(i) If MAA does not receive the information within thirty days of the date requested, MAA denies the original request within the next five working days on the basis of insufficient justification of medical/dental necessity;

(ii) If MAA receives the information within thirty days, MAA makes a final determination on the request within five working days of the receipt of that additional information.

(6) When ((the department)) MAA denies all or part of a request ((for medical services, including all or part of a requested service, the department shall)), MAA sends ((, within five working days of the decision, give)) the client and the provider written notice of the denial((.  The department shall ensure the notice states)) within five working days of the decision. The notice includes:

(a) The WAC references used as a basis for the decision;

(b) A summary statement of the specific facts ((the department)) MAA relied upon for the decision;

(c) An explanation of the reasons for the denial, including the reasons why the specific facts relied ((on)) upon did not meet the requirements for approval;

(d) When required ((under)) by subsection (3) of this section, a specific statement of the reasons and supporting facts for rejecting any medical/dental information or conclusions of an examining physician/dentist;

(e) Notice of the client's right to a fair hearing ((if the request is made within ninety days of the receipt of the denial)) and filing deadlines;

(f) ((The)) Instructions ((on)) about how to request the hearing;

(g) A statement that the client may be represented at the hearing by legal counsel or other representative; and

(h) Upon the client's request, the name and address of the nearest legal services office((; and

(i) If a fair hearing is requested, a medical assessment from other than the person involved in making the original decision may be obtained at the department's expense)).

(7) MAA may request an independent medical/dental assessment. MAA will pay for the independent assessment when MAA:

(a) Requests it; or

(b) Agrees that it is necessary.

[Statutory Authority: RCW 74.08.090.  94-10-065 (Order 3732), § 388-501-0165, filed 5/3/94, effective 6/3/94.  Formerly WAC 388-81-038.]

A client ((request for an exception to policy for medical care services denied by strict application of a rule or regulation shall require approval by medical assistance administration.  See WAC 388-200-1150 for exception to policy procedures)) or their provider may request prior authorization for MAA to pay for a noncovered medical or dental service, or related equipment. This is called an exception to rule.

(1) MAA cannot approve an exception to rule if the exception violates state or federal law or federal regulation.

(2) For MAA to consider the request, sufficient client-specific information and documentation must be included by the provider for the MAA medical director or designee to determine if:

(a) The client's clinical condition is so different from the majority that there is no equally effective, less costly covered service or equipment that meets the client's need(s); and

(b) The requested service or equipment will result in lower overall costs of care for the client.

(3) The MAA medical director or designee evaluates and considers requests on a case-by-case basis according to the information and documentation submitted by the provider.

(4) Within fifteen working days of MAA's receipt of the request, MAA notifies the provider and the client, in writing, of MAA's decision to grant or deny the exception to rule.

(5) Clients do not have a right to a fair hearing on exception to rule decisions.

[Statutory Authority: RCW 74.08.090.  94-10-065 (Order 3732), § 388-501-0160, filed 5/3/94, effective 6/3/94.  Formerly WAC 388-81-030.]

     The following sections of the Washington Administrative Code are repealed:

WAC 388-200-1160

Notification of exception to rule request and decision.

© Washington State Code Reviser's Office