Revised Version of LAC 40:I:2715 (1010 Process Rule)

Revised Version of LAC 40:I:2715 (1010 Process Rule)

§2715.Medical Treatment Schedule Authorization and Dispute Resolution

1. Purpose and Scope.

1. It is the purpose of this section to:

1. implement the efficient and timely delivery of necessary medical treatment to injured workers in accordance with R.S. 23:1203.1, including treatment in accordance with the workers’ compensation medical treatment schedule, variances from the medical treatment schedule, and treatment of diagnoses not covered by the medical treatment schedule;

1. identify the documentation to be provided to a payor to initiate a request for authorization of medical treatment;

1. identify the documentation to be provided to the OWC Medical Services section to initiate a request for review by the medical director or associate medical director;

1. identify the documentation to be provided to the OWC district offices to appeal a decision of the medical director;

1. provide for uniform forms, delays, and procedures for requests for authorization of and disputes concerning medical treatment.

1. This section shall not apply to the following:

1. Emergency Care

1. Pursuant to R.S. 23:1142, no prior consent by a payor is required for emergency medical procedure or treatment deemed immediately necessary by the treating health care provider. However, the health care provider shall bear the burden of proving the emergency nature of the diagnostic testing or treatment.

1. Any health care provider who authorizes or orders diagnostic testing or treatment subsequently determined not to have been of an emergency nature shall be responsible for all of the charges incurred in such testing or treatment. Fees for such services shall not be an enforceable obligation against the employee, the employer, or the employer’s workers’ compensation insurer unless they have agreed upon the treatment or diagnostic testing by the health care provider.

1. Non-Emergency Care not exceeding $750 - Pursuant to R.S. 23:1142, no prior consent by a payor is required for non-emergency medical testing or treatment not exceeding $750 per health care provider. However, no healthcare provider shall incur more than a total of $750 in non-emergency diagnostic testing or treatment without the mutual consent of the payor and the employee;

1. Denial of Compensability - No prior consent is required and this section shall not apply where the payordenies that the injury for which treatment is sought is compensable, or asserts that the employee has forfeited entitlement to benefits under the Workers’ Compensation Act.

1. Choice of Physician – this section does not apply to an employee’s request for a choice of physician or a change thereof, or to a carrier/self-insured employer’s request for an examination by its choice of physician, under R.S. 23:1121, et seq.

1. Pharmaceuticals –

1. Where a payor and an employee agree to the use of a “pharmacy benefits manager” or other third party entity retained by the payor to provide prescription drug management services (hereinafter referred to as a “PBM”), including reviewing, processing, and/or paying prescription drug claims, and prescriptions for pharmaceuticals are submitted to and reviewed by the PBM electronically, an LWC-WC-1010 under paragraph B of this section is not required.

1. Where a pharmaceutical subject to this subparagraph is denied or approved with modification by the PBM, any written documentation of the denial or modification may be submitted with a request for review by the medical director under paragraph C of this section, in place of an LWC-WC-1010.

1. As may be otherwise specified by statutory law or administrative rule.

1. As used herein, “current” means no more than 45 days prior to the date on which the LWC-WC-1010 form requesting treatment was submitted to the carrier/self-insured employer;

1. As used herein, “director” refers to the director of the Office of Workers’ Compensation;

1. As used herein, “days” means business days unless specified otherwise.

1. As used herein, “medical director” shall include both the medical director and any associate medical director for the Office of Workers’ Compensation Administration.

1. As used herein, “payor” means as defined in R.S. 23:1142.

1. Any notice, form, or other information required to be exchanged between a health care provider, a payor, an employee, an employee’s attorney, and/or the Office of Workers’ Compensation, under this section shall be transmitted electronically via facsimile or email, or only in the unavailability thereof, by first class mail.

1. Upon request by any healthcare provider, employee, or the employee’s attorney, all payors shall provide a fax number and/or email address to be used for purposes of these rules. If the fax number and/or email address provided is for a utilization review company contracted with the payor, then the payor shall also provide the name of the utilization review company.

1. Upon request by a payor, any health care provider, employee, or employee’s attorney shall provide a fax number and/or email address to be used for purposes of these rules, or written notice that no fax number or email address is available.

1. Any notice, form, or other information to an employee shall be sent concurrently to the employee’s attorney, if known. If the attorney does not have or refuses to provide a facsimile or email contact, such notice shall be sent by first class mail. Notice to the attorney shall be deemed notice to the employee.

1. Nothing herein relieves the employee from the burden of proving that any medical treatment, diagnostic testing, or other medical care is necessary as the result of a compensable work accident or occupational injury.

1. LWC-WC-1010 Process/Request for Authorization of Medical Treatment

1. Except as otherwise set forth herein, all requests formedical treatment, services, or care due under R.S. 23:1203 and/or R.S. 23:1203.1shall be submitted to the payor for authorization via an LWC-WC-1010/Request for Authorization/Carrier or Self Insured Employer Response;

1. Minimum Documentation to be Submitted with Initial Request for Authorization of Treatment–The healthcare provider should review requests for treatment to ensure they conform to R.S. 23:1203.1 and/or the medical treatment schedule applicable to the injury and diagnosis. In addition to the properly completed LWC-WC-1010, clinical documentation of the following shall accompany the request for treatment authorization:

1. current history provided to the level of the condition and as required by the medical treatment schedule;

1. current physical findings/clinical test results;

1. documentation of functional improvements from any prior treatment, if applicable;

1. most recent reports of relevant test/imaging results; and

1. current treatment plan, including services being requested along with the proposed frequency and duration.

1. Subsequent Request for Authorizations. After the initial request for authorization, subsequent requests for additional diagnostic testing or treatment by the same health care provider shall also be submitted on a LWC-WC-1010, but shall require only updates to the previously submitted information of Subparagraph 2.a-e above. The updates must demonstrate the patient’s current status sufficiently to document the need for the recommendedtesting or treatment in accordance with R.S. 23:1203.1. A brief history, changes in clinical findings such as orthopedic and neurological tests, and measurements of function and improvements thereof, with emphasis on the current, specific physical limitations, arenecessary when seeking approval of future care.

1. Request for Authorization of Treatment not Covered by the Medical Treatment Schedule.

1. Requests for authorization of medical care, services, and treatment not covered by the medical treatment schedule in accordance to R.S. 23:1203.1(M), must follow the same pre-authorization process established for other requests for medical care, services, and treatment.

1. Such a request exists when the requested care, services, or treatment are for a diagnosis not addressed by the medical treatment schedule.

1. In addition to the LWC-WC-1010 and the minimum information required by this section, the health care provider requesting such care, services, or treatment shall submit documentation sufficient to establish that the request is in accordance with R.S. 23:1203.1(D), including evidence based, peer-reviewed, scientific medical literature or other treatment guidelines meeting the criteria set forth in R.S. 23:1203.1, which support the requested treatment.

1. After receipt of the LWC-WC-1010, the supporting documentation, and the required clinical information in accordance with this Section, the payor shall determine whether the request for authorization is in accordance with R.S. 23:1203.1(D). In making this determination, the payor shall review the submitted documentation, but may apply another medical treatment guideline that meets the criteria of R.S. 23:1203.1(D).

1. Variance to Medical Treatment Schedule

1. Requests for authorization of medical care, services, and treatment that varies from the medical treatment schedule must follow the same prior authorization process established for all other requests for medical care, services, and treatment that require pre-authorization.

1. A variance exists in the following situations.

1. Although the diagnosis is covered by the medical treatment schedule, the requested care, services, or treatment is not recommended by or is contrary to the medical treatment schedule.

1. The requested care, services, or treatment is recommended by the medical treatment schedule, but for a different diagnosis or body part.

1. The requested care, services, or treatment involves a medical condition that complicates recovery of the claimant and is not addressed by the medical treatment schedule.

1. Pursuant to R.S. 23:1203.1(I), the party seeking the variancemust provide peer-reviewed, scientific medical literature to the medical director, demonstratingthat the proposed treatment is reasonably required to cure or relieve the injured worker from the effects of the injury or occupational disease.

1. Process to Request Authorization

1. Initial Request - To initiate the request for authorization of care under this Section, the health care provider shall submit a properly completed LWC-WC-1010to the payor, along with all documentation and informationrequired by this Section to support the request;

1. Request for Additional Informationvia LWC-WC-1010A

1. Upon receipt of the LWC-WC-1010, if the payor determines that the minimum information required by this Section has not been provided, then the payor shall, within 5 days of receipt of LWC-WC-1010, notify the health care provider of its determination.

1. Notice shall include the LWC-WC-1010 submitted by the health care provider,with the “first request” section completed to indicate a delay due to lack of information, and LWC-WC-1010A identifying and requesting the information that was not provided.

1. A copy of the LWC-WC-1010 and LWC-WC-1010(A), and all other information sent to the health care provider, shall be sent concurrently to the employee in accordance with paragraph A.8.

1. The health care provider shall respond to the payor’s request for additional information within 10 days of receipt of the request for additional information.

1. If the health care provider agrees that the additional information from the first request is due, then such information shall be provided, along with the properly completed LWC-WC-1010 and 1010A.

1. If the health care provider disagrees that the additional information in the first request is due, then the health care provider shall return the LWC-WC-1010 and 1010A with an explanation describing why the health care provider believes all required information has been previously provided.

1. If the health care provider fails to respond to the request for additional information within 10 days of receipt, then it shall be deemed that the LWC-WC-1010 is withdrawn, and the payor shall return the LWC-WC-1010 to the health care provider within 5 days indicating that it has been withdrawn accordingly. A copy of the LWC-WC-1010 shall concurrently be provided to the employee in accordance with paragraph A.8.

1. If the health care provider responds timely, then the carrier/self-insured employer shall within 5 days of the response, based on the information submitted, approve the requested treatment, approve the treatment with modification, or deny the treatment, as provided in paragraph B.5.c, below.

1. Response to Request for Treatment

1. Upon receipt of the LWC-WC-1010 and the minimum information required by this section, the payor shall have 5 days to notify the health care provider of its action on the request. A copy of the notice shall be concurrently provided to the employee in accordance with paragraph A.8. Based upon the medical information provided pursuant to this Section the payor will determine whether the request for authorization is in accordance with the medical treatment schedule, and:

1. return theLWC-WC-1010,indicating in the appropriate section on the form that “The requested treatment or testing is approved” if the request is in accordance with the medical treatment schedule and/or R.S. 23:1203.1; or

1. return the LWC-WC-1010, indicating in the appropriate section on the form “The requested treatment or testing is approved with modification” if the payor determines that modifications are necessary in order for the request for authorization to be in accordance with the medical treatment schedule and/or R.S. 23:1203.1, or that a portion of the request for authorization is denied because it is not in accordance with the medical treatment scheduleand/or R.S. 23:1203.1. The payor shall include with the LWC-WC-1010 a summary of reasons why a part of the request for authorization is not approved and explain any modification to the request for authorization; or

1. return the LWC-WC-1010, indicating in the appropriate section on the form “the requested treatment or testing is denied” if the payor determines that the request for authorization is not in accordance with the medical treatment scheduleand/or R.S. 23:1203.1. The payor shall include with the LWC-WC-1010 a summary of reasons why the request for authorization is not approved;

1. Summary of Reasons. The summary of reasons provided by the payor with a denial or an approval with modification shall include:

1. the name of the employee;

1. the date of accident;

1. the name of the health care provider requesting authorization;

1. the decision (approved with modification, or denied);

1. the clinical rationale to include a brief summary of the medical information reviewed;

1. the criteria applied to include specific references to the medical treatment schedule, or to another treatment guideline if the requested care, services or treatment is not covered by the medical treatment schedule;

1. whether the requested treatment or testing is denied because it is not related to an on-the-job injury, or is otherwise not compensable; and

1. a section labeled "Voluntary Reconsideration" that encourages the healthcare provider to contact the payor to discuss reconsideration and includes a phone number that will allow the health care provider to speak to a representative of the payor or its utilization review company with authority to reconsider a denial or approval with modification.

1. Pursuant to R.S. 23:1203.1, the 5 days to act on the request for authorization do not begin until the LWC-WC-1010 is received by the payor. However, if additional information is properly requested by the payor via submission of LWC-WC-1010(A), the delay shall commence upon receipt of a timely response from the health care provider or expiration of the time allowed for such response.

1. A payor who fails to respond to an LWC-WC-1010 within the 5 days provided in this subsection is deemed to have denied such request for authorization, and any interested party may thereafter seek review by the medical director pursuant to paragraph C.

1. Voluntary Reconsideration - Notwithstanding the foregoing, if apayor voluntarily reconsiders a denial of treatment or an approval with modification anddetermines that the requested care should be approved, it will return the LWC-WC-1010 to the health care provider andthe employee within 10 days after the original denial or approval with modification, indicating in the appropriate section on the form that "the prior denied or approved with modification request is now approved." Notice of the approval shall also be sent contemporaneously to the OWC Medical Services section if any party has requested review by the medical director.Such approval ends the utilization review process as it relates to the requested treatment, and any LWC-WC-1009 arising from the original decision shall be dismissed as moot.

1. Authorization for Evaluation and Management Visits

1. The medical treatment schedule provides that timely routine evaluation and management office visits with the treating physician are required for documentation of functional improvement resulting from previously authorized medical care, service and treatment.

1. A LWC-WC-1010 shall be required to initiate the request for authorization of the first routine evaluation and management office visit that occurs beyond the statutory non-emergency medical care monetary limit of $750 per health care provider.

1. If such routine evaluation and management office visit is approved as medically necessary, a LWC-WC-1010 shall not be required for any subsequent routine evaluation and management office visits with the employee’s treating physician during the first year after the accident date, not to exceed 12 visits including any visit that occurred prior to the first submission of a LWC-WC-1010.

1. A LWC-WC-1010 shall be required for a routine evaluation and management office visit after the 12thvisit or after one year from date of accident. If approved, an LWC-WC-1010 shall only be required on every fourth routine evaluation and management office visit thereafter. The payor may authorize more office visits over a defined period of time.

1. A routine evaluation and management office visit is limited to new and established patient evaluation and management office/outpatient visits, which includes but is not necessarily limited to, the following Current Procedural Terminology Codes: 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, and 99215.

1. Any medical care, services, or treatment performed at such routine evaluation and management office visit that will be billed as anything other than a routine evaluation and management office visit code shall require pre-approval with a request for authorization on a form LWC-WC-1010.

1. Nothing contained in this Section shall prevent the payor from denying any of the 12 routine evaluation and management office visits to occur within the first year of the accident date for reasons other than medical necessity to include but not be limited to causation, compensability, and medical relatedness.

1. After the first 12 routine evaluation and management office visits or after one year from the date of accident, the payor may deny as not medically necessary any request for a routine evaluation and management office visit.

1. Authorization for Active Therapeutic Exercise

1. If the payor determines on an otherwise compensable claim that modifications to a request for authorization on LWC-WC-1010 for active therapeutic exercise is necessary in order for the request for authorization to be in accordance with the medical treatment schedule, said request shall not be approved with modification for a number of treatments less than the minimum “time to produce effect” found in the applicable portion of the medical treatment schedule.

1. Notwithstanding the foregoing, the payor may approve with modification a request for active therapeutic exercise below the minimum “time to produce effect” found in the applicable portion of the medical treatment schedule if the payor has already approved active therapeutic exercise beyond the “frequency” and “maximum duration” found in the applicable portion of the medical treatment schedule.

1. Request for Review by Medical Director

1. An employee or health care provider who disagrees with a denial of a request for authorizationor an approval with modificationunder paragraph B, may file a request with the OWC Medical Services section seeking a review by the medical director. The request for review shall be submitted on an LWC-WC-1009/Disputed Claim for Medical Treatment and shall be filed within 15 calendar days of:

1. receipt of the LWC-WC-1010 indicating that care has been denied or approved with modification; or

1. expiration of the 5 day delay allowed for the payor to respond to a LWC-WC-1010 request.

1. The request for review shall include:

1. LWC-WC-1009/Disputed Claim for Medical Treatment, which shall state the reason for review is either;

1. a request for authorization that is denied; or

1. a request for authorization that is approved with modification; or

1. a request for authorization that is deemed denied due to the carrier/self-insured employer’s failure to respond; or

1. a request for a variance from the medical treatment schedule; and

1. a copy of the LWC-WC-1010 and if applicable, the LWC-WC-1010A; and

1. all of the information previously submitted to the payor with the LWC-WC-1010, including the clinical records showing that the requested treatment is medically necessary; and

1. In cases seeking a variance, the LWC-WC-1009 shall also include evidence-based, peer reviewed scientific medical literature which supports approval of the variance. The health care provider or claimant may also provide other medical treatment guidelines meeting the criteria set forth in La. R.S. 23:1203.1, and any other evidence demonstrating that a variance from the medical treatment schedule is reasonably required to cure or relieve the claimant from the effects of the injury or occupational disease given the circumstances.

1. A certification from the party filing the LWC-WC-1009 that such form and all supporting documentation has been provided to the payor, and the manner thereof.

1. All records submitted with the LWC-WC-1009 should be organized in a manner to facilitate proper review by the medical director, including removal of any non-clinical records and unnecessary duplicates.

1. The director may assess a fee not to exceed $1.00 per page for LWC-WC-1009s submitted with records in excess of seventy-five pages. Failure to pay the invoice within 10 days of receipt shall be deemed withdrawal of the LWC-WC-1009 request.

1. Pursuant to R.S. 23:1203.1, the medical director’s authority is limited to a clinical records review to determine whether the recommended care, services, or treatment is in accordance with the medical treatment schedule and/or R.S. 23:1203.1, or whether a variance from the medical treatment schedule is reasonably required as contemplated in R.S. 23:1203.1. Accordingly, the request for review shall not include non-clinical records. The Medical Services section may reject, such records, including the following:

1. billing, claims, surveillance, or other administrative reports

1. transcripts of depositions or recorded statements; however, in lieu thereof, the treating physician may submit a brief narrative report detailing why the proposed treatment should be approved.

1. audio/video recording

1. radiological films, e.g. MRIs, x-rays, etc. (However, written reports of such items documenting the results are acceptable clinical records).

Notwithstanding the foregoing, records that are rejected by the Medical Services section may be re-submitted on appeal to a workers’ compensation judge, in accordance with paragraph D.4.