Mississippi Administrative Code › Title 20 - Labor › Part 2 - Mississippi Workers' Compensation Medical Fee Schedule › INTRODUCTION › Section 20-2-III - MEDICAL NECESSITY

Current through June 25, 2024
The concept of medical necessity is the foundation of all
				  treatment and reimbursement made under the provision of §
									71-3-15,
				  Mississippi Code of 1972, as amended. For reimbursement to be made, services
				  and supplies must meet the definition of "medically necessary." The sole use of
				  extraneous guidelines, including but not limited to the ODG guidelines, to
				  determine the appropriateness or extent of treatment or reimbursement is
				  prohibited. Continuation of treatment shall be based on the concept of medical
				  necessity and predicated on objective or appropriate subjective improvements in
				  the patient's clinical status. Arbitrary limits on treatment or reimbursement
				  based solely on diagnosis or guidelines outside this Fee Schedule are not
				  permitted.
A. For the purpose of the
				Workers' Compensation Program, any reasonable medical service or supply used to
				identify or treat a work-related injury/illness which is appropriate to the
				patient's diagnosis, is based upon accepted standards of the health care
				specialty involved, represents an appropriate level of care given the location
				of service, the nature and seriousness of the condition, and the frequency and
				duration of services, is not experimental or investigational, and is consistent
				with or comparable to the treatment of like or similar non-work related
				injuries, is considered "medically necessary." The service must be widely
				accepted by the practicing peer group, based on scientific criteria, and
				determined to be reasonably safe. It must not be experimental, investigational,
				or research in nature except in those instances in which prior approval of the
				payer has been obtained. For purposes of this provision, "peer group" is
				defined as similarly situated physicians of the same specialty, licensed in the
				State of Mississippi, and qualified to provide the services in question.
B. Services for which
				reimbursement is due under this Fee Schedule are those services meeting the
				definition of "medically necessary" above and includes such testing or other
				procedures reasonably necessary and required to determine or diagnose whether a
				work-related injury or illness has been sustained, or which are required for
				the remedial treatment or diagnosis of an on-the-job injury, a work-related
				illness, a pre-existing condition affected by the injury or illness, or a
				complication resulting from the injury or illness, and which are provided for
				such period as the nature of the injury or process of recovery may require.
C. Treatment of conditions
				unrelated to the injuries sustained in an industrial accident may be denied as
				unauthorized if the treatment is directed toward the non-industrial condition
				or if the treatment is not deemed medically necessary for the patient's
				rehabilitation from the industrial injury.
D. Services that are experimental or
				investigational, including but not limited to CPT Category II and Category III
				codes, are not reimbursable for this Fee Schedule. Please refer to the MWCC
				website (www.mwcc.ms.gov [File Link Not Available]) for a list of some of these
				procedures.