North Dakota Administrative Code › Title 92 - Workforce Safety and Insurance › Article 92-01 - General Administration › Chapter 92-01-02 - Rules of Procedure - North Dakota Workers' Compensation Act › Section 92-01-02-29.1 - Medical necessity

Current through Supplement No. 393, July, 2024
1. A medical
				service or supply necessary to diagnose or treat a compensable injury, which is
				appropriate to the location of service, is medically necessary if it is widely
				accepted by the practicing peer group and has been determined to be safe and
				effective based on published, peer-reviewed, scientific studies.
2. Services that present a hazard in excess
				of the expected medical benefits are not medically necessary. Services that are
				controversial, obsolete, experimental, or investigative are not reimbursable
				unless specifically preapproved or authorized by the organization. Requests for
				authorization must contain a description of the treatment and the expected
				benefits and results of the treatment.
3. The organization will not authorize or pay
				for the following treatment:
a. Massage
				therapy unless specifically preapproved or otherwise authorized by the
				organization. Massage therapy must be provided by a licensed physical
				therapist, licensed occupational therapist, or licensed chiropractor.
b. Chemonucleolysis; acupressure;
				reflexology; rolfing; injections of colchicine except to treat an attack of
				gout precipitated by a compensable injury; injections of chymopapain;
				injections of fibrosing or sclerosing agents except where varicose veins are
				secondary to a compensable injury; and injections of substances other than
				cortisone, anesthetic, or contrast into the subarachnoid space (intrathecal
				injections).
c. Treatment to
				improve or maintain general health (i.e., prescriptions or injections of
				vitamins, nutritional supplements, diet and weight loss programs, programs to
				quit smoking) unless specifically preapproved or otherwise authorized by the
				organization. Over-the-counter medications may be allowed in lieu of
				prescription medications when approved by the organization and prescribed by
				the health care provider and dispensed and processed according to the current
				pharmacy transaction standard. Dietary supplements, including minerals,
				vitamins, and amino acids are reimbursable if a specific compensable dietary
				deficiency has been clinically established in the claimant. Vitamin B-12
				injections are reimbursable if necessary because of a malabsorption resulting
				from a compensable gastrointestinal disorder.
d. Articles such as beds, hot tubs, chairs,
				Jacuzzis, vibrators, heating pads, home furnishings, waterbeds, exercise
				equipment, cold packs, hot packs, and gravity traction devices are not
				compensable except at the discretion of the organization under exceptional
				circumstances.
e. Vertebral axial
				decompression therapy (Vax-D treatment). f. Intradiscal electrothermal
				annuloplasty (IDET).
g.
				Prolotherapy (sclerotherapy).
h.
				Surface electromyography (surface EMG).
i. Athletic trainer services that are
				provided to a claimant via an agreement, or a contract of employment between a
				trainer and a claimant's employer, or an entity closely associated with the
				employer.
j. Spine strengthening
				program (e.g. MedX or SpineX or other substantially equivalent
				program).
k. Electrodiagnostic
				studies performed by electromyographers who are not certified or eligible for
				certification by the American board of electrodiagnostic medicine, American
				board of physical medicine and rehabilitation, or the American board of
				neurology and psychiatry's certification in the specialty of clinical
				neurophysiology. Nerve conduction study reports must include either laboratory
				reference values or literature-documented normal values in addition to the test
				values to be eligible for payment.
l. Trigger point injections. No more than
				twenty injections may be paid over the life of a claim. If a trigger point
				injection is administered, the organization may not pay for additional
				modalities such as cryotherapy and osteopathic manipulations performed in
				conjunction with the trigger point injection. For purposes of this paragraph,
				injections billed under CPT code 20552 or 20553 count as a single
				injection.
m. Acupuncture therapy.
				No more than eighteen treatments may be paid for the life of the claim. The
				organization may waive this requirement in conjunction with programs designed
				to ensure the ongoing evolution of managed care to meet the needs of injured
				workers and providers.
n. Dry
				needling.
o. Opioid therapy
				exceeding ninety milligrams morphine equivalents daily unless the following
				criteria are met when a prescription exceeding ninety milligrams morphine
				equivalents daily is exceeded and as the organization deems necessary:
(1) Documented treatment plan consistent with
				the organization's utilization review process;
(2) Participation in a psychosocial consult
				with a health care provider, preferably a licensed psychologist or psychiatrist
				outside the health care provider's network, to address the risk and harms of
				opioid use under the centers for disease control and prevention "Guideline for
				Prescribing Opioids for Chronic Pain". The psychosocial consult should include
				standardized screening using validated tools for mental health and substance
				abuse conditions, as well as a risk stratification plan; and
(3) Recent documentation of attempts to taper
				opioid use and employ non-opioid therapies for pain control.
p. Benzodiazepine therapies
				extending beyond a cumulative duration of four weeks, unless prescribed for
				treatment of a compensable anxiety disorder. In addition, the following
				criteria must be met when the cumulative duration of four weeks is exceeded and
				as the organization deems necessary:
(1) A
				documented treatment plan consistent with the organization's utilization review
				process;
(2) Participation in a
				psychosocial consult with a health care provider, preferably a licensed
				psychologist or psychiatrist outside the health care provider's network, to
				address the risk and harms of benzodiazepine use. The psychosocial consult
				should include standardized screening using validated tools for mental health
				and substance abuse conditions, as well as a risk stratification plan;
				and
(3) Recent documentation of
				attempts to taper benzodiazepine use and employ non-benzodiazepine
				therapies.