Kentucky Administrative Regulations › Title 803 - LABOR CABINET › Chapter 25 - Department of Workers' Claims › Section 803 KAR 25:260 - Treatment Guidelines

Current through Register Vol. 51, No. 1, July 1, 2024
RELATES TO:
				KRS
				342.0011(13),
				342.020,
				342.035.
NECESSITY, FUNCTION, AND CONFORMITY:
				KRS
				342.260(1) requires the
				commissioner to promulgate administrative regulations necessary to carry on the
				work of the department and the work of administrative law judges if those
				administrative regulations are consistent with KRS Chapter 342 and KRS Chapter
				13A.
				KRS
				342.035(8)(a) requires the
				commissioner to develop or adopt practice parameters or evidence-based
				treatment guidelines for medical treatment for use by medical providers under
				KRS Chapter 342 and to promulgate administrative regulations to implement the
				developed or adopted practice parameters or evidence-based treatment
				guidelines. This administrative regulation adopts treatment guidelines and
				provides guidance to implement them. This administrative regulation does not
				abrogate the right, as provided in
				KRS
				342.020, of an injured employee to choose his
				treating physician, or an employer to participate in a managed health care
				system.
Section 1. Definitions.
(1) "Carrier" is defined by
			 KRS
			 342.0011(6).
(2) "Commissioner" is defined by
			 KRS
			 342.0011(9).
(3) "Department" is defined by
			 KRS
			 342.0011(8).
(4) "Employee" means those natural persons
			 constituting an employee subject to the provisions of KRS Chapter 342 as
			 defined in
			 KRS 342.640
			 and the employee's legal counsel.
(5) "Employer" means those persons
			 constituting an employer as defined in
			 KRS
			 342.630, the employer's carrier, insurance
			 carrier, self-insured group or other payment obligor, third party
			 administrator, other person acting on behalf of the employer in a workers'
			 compensation matter, and the employer's legal counsel.
(6) "Evidence-based medicine" means the
			 process and use of relevant information from peer-reviewed clinical and
			 epidemiologic research to address a clinical issue by weighing the attendant
			 risks and benefits to determine whether proposed diagnostic or therapeutic
			 procedures are appropriate in light of their high probability of producing the
			 best and most favorable outcome.
(7) "Insurance carrier" is defined by
			 KRS
			 342.0011(22).
(8) "Maximum medical improvement" means the
			 point of stabilization in an employee's recovery from a work injury where
			 substantial improvement in the human organism is no longer likely.
(9) "Medical emergency" means the sudden
			 onset of a medical condition manifested by acute symptoms of sufficient
			 severity, including severe pain, that in the absence of immediate medical
			 attention may reasonably be expected to result in placing the patient's health
			 or bodily functions in serious jeopardy or serious dysfunction of any body
			 organ or part.
(10) "Medical
			 payment obligor" means any employer, carrier, insurance carrier, self-insurer,
			 or any person acting on behalf of or as an agent of the employer, carrier,
			 insurance carrier, or self-insurer.
(11) "Medical provider" means physicians and
			 surgeons, psychologists, optometrists, dentists, podiatrists, osteopathic and
			 chiropractic practitioners, physician assistants, and advanced practice
			 registered nurses, acting within the scope of their license.
(12)
(a)
			 "Medically necessary" or "medical necessity" means healthcare services,
			 including medications, that a medical provider, exercising prudent clinical
			 judgment, would provide to a patient for the purpose of preventing, evaluating,
			 diagnosing or treating an illness, injury, disease or its symptoms, and that
			 are:
1. In accordance with generally accepted
			 standards of medical practice;
2.
			 Clinically appropriate, in terms of type, frequency, extent, site and duration;
			 and
3. Considered effective for the
			 patient's illness, injury, or disease.
(b) Treatment primarily for the convenience
			 of the patient, physician, or other healthcare provider does not constitute
			 medical necessity.
(13)
			 "Physician" is defined by
			 KRS
			 342.0011(32).
(14) "Preauthorization" means the process
			 whereby payment for a medical service or course of treatment is assured in
			 advance by a carrier.
(15)
			 "Statement for services" is defined by
			 803
			 KAR 25:096, Section 1(5).
(16) "Treatment guidelines" or "guidelines"
			 are the treatment guidelines developed or adopted by the commissioner pursuant
			 to
			 KRS
			 342.035(8)(a).
(17) "Utilization Review" is defined by
			 803
			 KAR 25:190, Section 1(6).