reglab/statecodes huggingface dataset:
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-19 - Self Insurance Risk Pools › Section 85-19-10 - Converting to Insured Employer Status or Becoming Inactive

Current through Register Vol. XLI, No. 28, July 12, 2024
On or after July 1, 2004, any active self-insured employer
				  who:
(i) becomes an insured employer
				or who, either voluntarily or involuntarily, has its self-insured status
				terminated; and
(ii) did not enter
				into a voluntary buy out for its liability prior to December 31, 2005, or enter
				into an agreement for an involuntary buy out, shall maintain surety in an
				amount sufficient to cover its liabilities during its period of self-insurance
				consistent with this rule and W. Va. Code St. R. §
									85-18-1 et
				seq.; any such employer shall also be assessed Security Pool and Guaranty Pool
				assessments for a period of ten (10) years from the termination of self-insured
				status: Provided, That in these circumstances, Guaranty Pool assessments for
				each year shall be in the amount of five percent (5%) of the prior year's
				indemnity payments or five thousand dollars ($5,000.00), whichever is greater;
				Provided, further, That such assessments are subject to suspension as provided
				in subsection 9.2. of this rule. This provision is not to be construed as
				excusing any obligation of a terminated self-insured employer imposed by
				chapter twenty-three of the West Virginia Code or the rules promulgated
				thereunder.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-20 - Medical Management Of Claims, Guidelines For Impairment Evaluations, Evidence, And Ratings, And Ranges Of Permanent Partial Disability Awards › Section 85-20-2 - Purpose of Rule

Current through Register Vol. XLI, No. 28, July 12, 2024
2.1. The
				purpose of this rule is to implement the provisions of W. Va. Code §
									23-4-3b(b)
				and the other provisions of the Code that are identified in Section 1.1
				above.
2.2. Upon termination of the
				Commission, regulatory enforcement of this exempt legislative rule shall
				transfer to the insurance commissioner to be administered in a manner otherwise
				consistent with chapter twenty-three of the West Virginia Code. W.Va. Code
				§
									23-2C-22.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-20 - Medical Management Of Claims, Guidelines For Impairment Evaluations, Evidence, And Ratings, And Ranges Of Permanent Partial Disability Awards › Section 85-20-3 - Definitions

Current through Register Vol. XLI, No. 28, July 12, 2024
As used in these rules, the following terms have the stated
				  meanings unless the context of a specific use clearly indicates another meaning
				  is intended.
3.1. "Code of West
				Virginia" and "West Virginia Code" means the West Virginia Code of 1931 as
				amended.
3.2. "Executive Director"
				means the Executive Director of the West Virginia Workers' Compensation
				Commission as provided pursuant to the provisions of W. Va. Code §
									23-1-1b.
3.3. "Commission" means the West Virginia
				Workers' Compensation Commission as provided for by W. Va. Code §
									23-1-1,
				et seq.
3.4. "Health Care Vendor"
				or "Health Care Provider" refers to health care providers, including providers
				of rehabilitation services within the meaning of W. Va. Code §
									23-4-9,
				both in- and out-of-state who have signed provider agreements with the West
				Virginia Workers' Compensation Commission, insurance commissioner, self-insured
				employer or private carrier, whichever is applicable, to provide health care
				for injuries or illnesses covered by Chapter 23 of the Code. For this Rule, the
				terms shall mean any person, firm, corporation, partnership, association,
				agency, institution, or other legal entity providing any kind of services or
				equipment. The terms include, but are not limited to, hospitals, medical
				doctors, dentists, chiropractors, vocational rehabilitation counselors,
				vocational rehabilitation service providers, qualified rehabilitation
				professional, osteopathic physicians, pharmacists, podiatrists, physical
				therapists, occupational therapists, massage therapists, psychologists,
				naturopathic physicians, and durable medical equipment suppliers.
3.5. "Office of Judges" refers to the Office
				of Judges, as set forth in W. Va. Code §
									23-5-8.
3.6. "This rule" means the present exempt
				legislative rule that is designated in the caption here as title 85, series
				20.
3.7. The following will be
				referred to throughout the rule by the abbreviation indicated.
a. Magnetic resonance imaging - MRI
b. Encephalogram - EEG
c. Computer Assisted Tomogram - CT scan d.
				Electromyelogram - EMG
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-20 - Medical Management Of Claims, Guidelines For Impairment Evaluations, Evidence, And Ratings, And Ranges Of Permanent Partial Disability Awards › Section 85-20-4 - Adoption of Standards and Acceptance of Rules

Current through Register Vol. XLI, No. 28, July 12, 2024
4.1. The treatment guidelines, standards,
				protocols, and limitations thereon provided for the injuries and diseases
				listed in this section are designed to assist health care providers in the
				evaluation and treatment of injured workers. The provisions of this Rule are
				not intended to strictly dictate results and it is recognized that there may be
				extraordinary cases that require treatments in addition to the treatments set
				forth in this Rule. However the treatments and limitations on treatments set
				forth in this Rule are presumed to be medically reasonable and treatments in
				excess of those set forth in this rule are presumed to be medically
				unreasonable. A preponderance of evidence, including but not limited to,
				detailed and documented medical findings, peer reviewed medical studies, and
				the elimination of causes not directly related to a compensable injury or
				disease, must be presented to establish that treatments in excess of those
				provided for in this Rule are medically reasonable. To receive reimbursement
				from the Commission, insurance commissioner, self-insured employer or private
				carrier, whichever is applicable, for treatment in excess of that provided for
				in this Rule, all providers must thoroughly document and explain the action
				taken and the basis for the deviation from this Rule and shall receive
				authorization before providing said treatment.
4.2. Except as provided for in section 5.11
				of this Rule, providing treatment to an injured worker, filling prescriptions
				for an injured worker, and/or acceptance of payment for treatment, devices, or
				medications provided to an injured worker constitutes acceptance by the medical
				provider of the Commission's or Insurance Commissioner's rules and fee
				schedules.
4.3. Failure of the
				medical provider to timely submit appropriately completed forms, failure to
				comply with this Rule or any fee schedule or billing guideline, as may be from
				time to time amended, and any attempt to seek reimbursement in excess of the
				levels provided for in this Rule may be considered as an abusive practice for
				purposes of W. Va. Code §
									23-4-3c
				and may be considered as evidence of conduct in violation of W. Va. Code §
									61-3-24g
.
All medical reports and fee bills must be signed by the medical vendor
				rendering the services or his authorized representative. If the report or bill
				is not submitted electronically, the medical vendor's name must be legibly
				printed or typed beneath the signature.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-20 - Medical Management Of Claims, Guidelines For Impairment Evaluations, Evidence, And Ratings, And Ranges Of Permanent Partial Disability Awards › Section 85-20-5 - Qualified Providers and Registration

Current through Register Vol. XLI, No. 28, July 12, 2024
5.1. To receive payment as a health care
				provider, a provider must be enrolled as an active vendor with the Commission.
				Providers may be reimbursed only for services actually provided or supervised
				and for which the vendor is duly licensed. To enroll, the provider must submit
				the applicable application to the Commission, completed in its entirety, along
				with all documentation requested by the Commission, including, but not limited
				to, all professional licenses, board certificates, business licenses,
				accreditation certificates, and/or operating permits held by the provider in
				this or any other state.
a. Upon termination
				of the Commission, no registration is required of health care providers. Health
				care professionals are required to verify and provide proof of their licensing
				and certification, including, but not limited to, all professional licenses,
				board certificates, business licenses, accreditation certificates, and/or
				operating permits held by the provider in this or any other state, to the
				Insurance Commissioner, self-insured employer or private carrier, whomever
				services are provided under this rule. In turn the Insurance Commissioner,
				self-insured employer or private carrier, is required to maintain this proof
				that the health care provider is qualified to provide services under this
				rule.
b. Providers must advise the
				Commission, the Insurance Commissioner, self-insured employer or private
				carrier, whichever is applicable, if their license to practice medicine has
				ever been suspended or terminated by the appropriate authority in West Virginia
				or any other state and whether the provider has been convicted of any crime in
				relation to his or her practice, or any felony. Providers with address or
				telephone number changes must advise the Commission, the Insurance
				Commissioner, self-insured employer or private carrier, whichever is
				applicable, in writing (by mail or facsimile), providing both old and new
				information and their tax identification number on letterhead.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-20 - Medical Management Of Claims, Guidelines For Impairment Evaluations, Evidence, And Ratings, And Ranges Of Permanent Partial Disability Awards › Section 85-20-7 - Initial Reporting of Injury

Current through Register Vol. XLI, No. 28, July 12, 2024
7.1. It is the responsibility of the injured
				worker to notify the employer, Commission, and medical provider when there is
				reason to believe the injury or condition is industrial in nature. Conversely,
				if the medical provider discovers a condition which he or she believes to be
				work related or has reason to believe an injury is work related, he or she must
				so notify the injured worker. Once such a determination is made by either the
				injured worker or the medical provider, the appropriate form(s) must be
				immediately submitted. Failure of the medical provider to timely submit the
				appropriately completed forms may be considered as an abusive practice for
				purposes of W. Va. Code §
									23-4-3c.
				Failure of the injured worker to timely submit appropriately completed forms
				may be considered and given appropriate weight by the Commission, Insurance
				Commissioner, private carrier or self-insured employer, whichever is
				applicable, in determining compensability or any other matter.
7.2. It is the medical provider's
				responsibility to ascertain whether he or she is the first attending
				practitioner. If so, the medical provider will take the following action:
a. Give emergency treatment.
b. Immediately complete and forward the
				Initial Report of Injury to the Commission, Insurance Commissioner, private
				carrier or self-insured employer, whichever is applicable, and the
				employer.
c. Instruct and give
				assistance to the injured worker in completing his or her portion of the report
				of accident. The Initial report of Injury shall include a narrative report
				containing the following information so there is no delay in adjudication of
				the claim or payment of compensation:
1.
				Complete history of the industrial accident or exposure.
2. Comprehensive description of physical
				findings and prognosis.
3. Specific
				diagnosis with ICD-9-CM code(s) and narrative definition relating to the
				injury.
4. Type of treatment
				rendered.
5. Known medical,
				emotional or social conditions which may influence recovery or cause
				complications.
6. Estimated time
				loss due to the injury.
d. To the extent the information called for
				in (c)(1) - (c)(6) is not required on the Initial Report of Injury in use by
				the Commission, Insurance Commissioner, private carrier or self-insured
				employer, whichever is applicable, the medical provider shall complete the
				appropriate form in its entirety and provide the additional information in the
				form of a narrative report.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-20 - Medical Management Of Claims, Guidelines For Impairment Evaluations, Evidence, And Ratings, And Ranges Of Permanent Partial Disability Awards › Section 85-20-8 - Additional Reporting Requirements

Current through Register Vol. XLI, No. 28, July 12, 2024
8.1. Whenever requested by the Commission,
				Insurance Commissioner, private carrier or self-insured employer, whichever is
				applicable, and at least every ninety (90) days in situations regarding the
				continuation of temporary total disability benefits, the medical provider shall
				report on the condition and treatment of the injured worker. The following
				information must be included in this type of report.
a. The condition(s) diagnosed including
				ICD-9-CM codes and the objective and subjective findings.
b. Their relationship, if any, to the
				industrial injury or exposure.
c.
				Outline of proposed treatment program, its length, components, and expected
				prognosis including an estimate of when treatment should be concluded and
				condition(s) stable. An estimated return to work date should be included. The
				probability, if any, of permanent partial disability resulting from industrial
				conditions should be noted.
d. If
				the worker has not returned to work, the attending doctor should indicate
				whether a vocational assessment will be necessary to evaluate the worker's
				ability to return to work and why.
e. If the worker has not returned to work, a
				doctor's estimate of physical and functional capacities should be included with
				the report. If further information regarding physical and functional capacities
				is needed or required, a performance-based functional capacity evaluation can
				be requested. Functional capacity evaluations shall be conducted by a licensed
				health care provider approved by the Commission, Insurance Commissioner,
				private carrier or self-insured employer, whichever is applicable, to perform
				this testing.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-20 - Medical Management Of Claims, Guidelines For Impairment Evaluations, Evidence, And Ratings, And Ranges Of Permanent Partial Disability Awards › Section 85-20-9 - Coverage and Billing Provisions

Current through Register Vol. XLI, No. 28, July 12, 2024
9.1. The Commission, Insurance Commissioner,
				private carrier or self-insured employer, whichever is applicable, will pay for
				health care services, durable medical and other goods and other supplies and
				medically related items as may be reasonably required. The Commission,
				Insurance Commissioner, private carrier or self-insured employer, whichever is
				applicable, will only pay for those services or items that have a direct
				relationship to the work related injury or disease, as determined in the sole
				discretion of the Commission, Insurance Commissioner, private carrier or
				self-insured employer, whichever is applicable.
9.2. A medical coverage decision is a general
				policy decision to be made in the sole discretion of the Commission, Insurance
				Commissioner, private carrier or self-insured employer, whichever is
				applicable, to include or exclude a specific health care service or supply as a
				covered benefit. These decisions are made to insure quality of care and prompt
				treatment of workers. Medical coverage decisions include, but are not limited
				to, decisions on health care services and supplies rendered for the purpose of
				diagnosis, treatment or prognosis, such as:
a. Ancillary services including, but not
				limited to, home health care services ambulatory services, specific
				rehabilitative modalities;
b.
				Devices;
c. Diagnostic
				tests;
d. Drugs, biologics, and
				other therapeutic modalities;
e.
				Durable medical equipment;
f.
				Procedures;
g. Prognostic
				tests;
h. Supplies; and
i. Inpatient hospital stays and associated
				charges
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-20 - Medical Management Of Claims, Guidelines For Impairment Evaluations, Evidence, And Ratings, And Ranges Of Permanent Partial Disability Awards › Section 85-20-10 - Supplies

Current through Register Vol. XLI, No. 28, July 12, 2024
HCPCS code A4550 (Surgical Trays) is a status B code and is
				  not reimbursable for office procedures. Codes with a status B are bundled
				  services for which no separate payment may be made. Supply costs are included
				  in the global fee allowance for surgical procedures performed in an office
				  setting. Code 99070 continues to be a non-covered, bundled
				  code.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-20 - Medical Management Of Claims, Guidelines For Impairment Evaluations, Evidence, And Ratings, And Ranges Of Permanent Partial Disability Awards › Section 85-20-11 - Vision Care

Current through Register Vol. XLI, No. 28, July 12, 2024
Ophthalmologists and optometrists may use CPT codes for
				  reporting procedures and professional services. Reimbursement for vision care
				  equipment such as spectacles, contact lenses, etc., should be requested using
				  appropriate HCPCS Level II codes. Repair or replacement of vision care
				  equipment damaged in an accident will not be approved for payment unless the
				  injured worker suffers a compensable physical injury in the
				  accident.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-20 - Medical Management Of Claims, Guidelines For Impairment Evaluations, Evidence, And Ratings, And Ranges Of Permanent Partial Disability Awards › Section 85-20-13 - Coverage Medication Checks

Current through Register Vol. XLI, No. 28, July 12, 2024
Medication checks may be billed if needed, but should be
				  reported using the appropriate Evaluation and Management or Drug Management
				  procedure codes. Medication checks for psychiatric medication require the use
				  of an ICD-9-CM code to identify the compensable mental health
				  condition.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-20 - Medical Management Of Claims, Guidelines For Impairment Evaluations, Evidence, And Ratings, And Ranges Of Permanent Partial Disability Awards › Section 85-20-14 - Medication/Injections

Current through Register Vol. XLI, No. 28, July 12, 2024
Professional services for administering injections to an
				  injured worker in an office setting for the treatment of a compensable injury
				  may be reimbursable. Effective January 1, 2003, the cost of medication
				  administered through other-than-oral method may be billed as a separate line
				  item using appropriate HCPCS II "J" codes. Legend drugs dispensed by physicians
				  will not be reimbursed except in emergency situations.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-20 - Medical Management Of Claims, Guidelines For Impairment Evaluations, Evidence, And Ratings, And Ranges Of Permanent Partial Disability Awards › Section 85-20-15 - Dental Services

Current through Register Vol. XLI, No. 28, July 12, 2024
15.1.
				Standard dental treatment necessary as a result of a compensable injury to the
				face or head is covered under the Workers' Compensation program. Repair or
				replacement of dentures and other dental appliances damaged in an accident will
				not be approved for payment unless the injured worker suffers a compensable
				physical injury in the accident. Except in cases of emergency, prior
				authorization must be obtained for any and all dental services
				provided.
15.2. The Commission,
				Insurance Commissioner, private carrier or self-insured employer, whichever is
				applicable, will not approve payment for treatment of a preexisting dental
				deficiency or disease, unless it is clearly established that such preexisting
				condition is prohibiting treatment of or recovery from an industrial injury. In
				such cases the Commission, Insurance Commissioner, private carrier or
				self-insured employer, whichever is applicable, must be provided with a
				complete report of the preexisting condition and authorization granted prior to
				rendering treatment.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-20 - Medical Management Of Claims, Guidelines For Impairment Evaluations, Evidence, And Ratings, And Ranges Of Permanent Partial Disability Awards › Section 85-20-16 - Experimental Procedures

Current through Register Vol. XLI, No. 28, July 12, 2024
16.1.
				Services investigative or experimental in nature or unsafe and not accepted by
				the general medical community are not reimbursable by the Commission, Insurance
				Commissioner, private carrier or self-insured employer, whichever is
				applicable.
16.2. To be considered
				for reimbursement by the Commission, Insurance Commissioner, private carrier or
				self-insured employer, whichever is applicable, medical devices must have gone
				through FDA pre-market notification submission or pre-market approval
				application or be exempt for commercial distribution on the national level.
				Pre-market approval designation is preferred because this designation requires
				sufficient information to reasonably assure the safety and effectiveness of the
				device.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-20 - Medical Management Of Claims, Guidelines For Impairment Evaluations, Evidence, And Ratings, And Ranges Of Permanent Partial Disability Awards › Section 85-20-17 - Unusual treatment

Current through Register Vol. XLI, No. 28, July 12, 2024
17.1. In
				cases requiring unusual treatment not contemplated under ordinary
				circumstances, the medical vendor must inform the Commission, Insurance
				Commissioner, private carrier or self-insured employer, whichever is
				applicable, immediately of the condition or complications present. If the
				necessity for additional treatment and its causal relationship with the
				compensable injury is clearly indicated, authorization for such treatment may
				be granted by the Commission, Insurance Commissioner, private carrier or
				self-insured employer, whichever is applicable, if it otherwise is deemed to be
				medically reasonable and additional professional fees may be paid at a rate
				commensurate with the services rendered in addition to the fee specified by the
				Commission, Insurance Commissioner, private carrier or self-insured employer,
				whichever is applicable.
17.2. New
				or experimental therapies always require prior authorization from the
				Commission, Insurance Commissioner, private carrier or self-insured employer,
				whichever is applicable. The Commission, Insurance Commissioner, private
				carrier or self-insured employer, whichever is applicable, will require a
				detailed, credible and otherwise sufficient explanation of the anticipated
				outcomes of the proposed therapy. The Commission, Insurance Commissioner,
				private carrier or self-insured employer, whichever is applicable, may
				authorize a trial of the therapy, for a duration identified by the Commission,
				Insurance Commissioner, private carrier or self-insured employer, whichever is
				applicable, prior to acceptance of any modality. Approval of new or
				experimental therapies is within the sole discretion of the Commission,
				Insurance Commissioner, private carrier or self-insured employer, whichever is
				applicable.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-20 - Medical Management Of Claims, Guidelines For Impairment Evaluations, Evidence, And Ratings, And Ranges Of Permanent Partial Disability Awards › Section 85-20-18 - Organ Transplants

Current through Register Vol. XLI, No. 28, July 12, 2024
18.1.
				Transplants are not generally accepted or reimbursed by the Commission,
				Insurance Commissioner, private carrier or self-insured employer, whichever is
				applicable; however, requests are reviewed on a case-by-case basis. All
				transplants must be pre-approved by the Commission, Insurance Commissioner,
				private carrier or self-insured employer, whichever is applicable, prior to
				issuance of authorization.
18.2.
				Transplants which are needed, in whole or in part, because of an intervening
				cause, such as long term alcohol consumption, smoking, or other tobacco use
				shall be declined coverage by the Commission, Insurance Commissioner, private
				carrier or self-insured employer, whichever is applicable.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-20 - Medical Management Of Claims, Guidelines For Impairment Evaluations, Evidence, And Ratings, And Ranges Of Permanent Partial Disability Awards › Section 85-20-19 - Other Non-Covered Services

Current through Register Vol. XLI, No. 28, July 12, 2024
19.1. Diagnostic Studies. No payment is
				allowed for:
a. Plethysmography;
b. Temperature gradient studies;
c. Fomentation;
d. Thermography;
e. Routine lab studies in back injury claims;
				or
f. Routine X-rays which the
				Commission, Insurance Commissioner, private carrier or self-insured employer,
				whichever is applicable, determines, in its sole discretion, are medically
				unreasonable or medically unsupported as defined under 85 C.S.R. 28.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-20 - Medical Management Of Claims, Guidelines For Impairment Evaluations, Evidence, And Ratings, And Ranges Of Permanent Partial Disability Awards › Section 85-20-20 - Payment for appearance at hearings

Current through Register Vol. XLI, No. 28, July 12, 2024
A party causing the cancellation of an examination of a
				  medical doctor, osteopath, or chiropractor may be charged a $100 cancellation
				  fee by said provider if forty-eight (48) hours notice of said cancellation is
				  not provided.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-20 - Medical Management Of Claims, Guidelines For Impairment Evaluations, Evidence, And Ratings, And Ranges Of Permanent Partial Disability Awards › Section 85-20-21 - Treatment of unrelated conditions

Current through Register Vol. XLI, No. 28, July 12, 2024
The Commission, Insurance Commissioner, private carrier or
				  self-insured employer, whichever is applicable, may pay for treatment of a
				  condition which was not caused by the injury only if the Commission, Insurance
				  Commissioner, private carrier or self-insured employer, whichever is
				  applicable, determines, in its sole discretion, that the unrelated condition is
				  preventing recovery by aggravating the occupational injury. Any unrelated
				  condition must be reported to the Commission, Insurance Commissioner, private
				  carrier or self-insured employer, whichever is applicable, before payment is
				  considered. Pre-existing conditions which prevent recovery but do not aggravate
				  the compensable injury shall not be covered.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-20 - Medical Management Of Claims, Guidelines For Impairment Evaluations, Evidence, And Ratings, And Ranges Of Permanent Partial Disability Awards › Section 85-20-23 - Miscellaneous Coverage and Reimbursement Issues

Current through Register Vol. XLI, No. 28, July 12, 2024
23.1. Hernia. The Commission, Insurance
				Commissioner, private carrier or self-insured employer, whichever is
				applicable, shall not approve payment for conservative treatment of an
				otherwise compensable hernia condition, except for the initial examination for
				diagnostic purposes, and except where it is shown that the employee has some
				chronic disease or is otherwise in such physical condition that it is
				considered unsafe for him to undergo such operation. Payment for surgical
				repair of a hernia cannot be considered until all required forms have been
				filed and the claim determined compensable.
23.2. Amputation reports. In cases involving
				amputations, the physician must mark the exact line of amputation on the
				prescribed form (Amputation Chart). To avoid error, the exact point of
				amputation must also be described in the written report and the Amputation
				Chart and report must be carefully checked to be certain that they agree.
IV. SPECIFIC TREATMENT GUIDELINES
The following are treatment guidelines for specific
				  conditions. However, the usage of the term "guidelines" should not be
				  interpreted to suggest that the guidelines are to be given any less legal
				  weight than an exempt legislative rule is otherwise given. The provisions of
				  Section 4 of this Rule apply in their entirety to these guidelines.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-20 - Medical Management Of Claims, Guidelines For Impairment Evaluations, Evidence, And Ratings, And Ranges Of Permanent Partial Disability Awards › Section 85-20-24 - Treatment Guidelines: Post Concussion Syndrome

Current through Register Vol. XLI, No. 28, July 12, 2024
24.1. Post concussion syndrome is a clinical
				syndrome characterized by a variety of vague symptoms including a headache,
				dizziness, memory dysfunction and depression, following head trauma. There is
				little relationship between the serious nature of the trauma and the severity
				and duration of the symptoms.
24.2.
				The diagnostic criteria consists of a persistent dysfunctional state following
				head trauma without clinical or laboratory sign of serious intracranial or
				cervical spine disorder.
24.3. The
				appropriate diagnostic tests and evaluations are as follows:
a. Neurological examination;
b. MRI;
c. EEG;
d. Electronystagmyogram; and
e. Neuropsychological testing if no
				improvement after four weeks.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-20 - Medical Management Of Claims, Guidelines For Impairment Evaluations, Evidence, And Ratings, And Ranges Of Permanent Partial Disability Awards › Section 85-20-25 - Treatment Guidelines: Corneal Abrasion

Current through Register Vol. XLI, No. 28, July 12, 2024
25.1. Corneal abrasion is usually caused by a
				foreign body striking the eye resulting in a disruption of the corneal
				epithelium. The foreign body does not remain in the eye.
25.2. The diagnostic criteria consists of
				complaints of pain and blurred vision. Photophobia may or may not be
				present.
25.3. Appropriate
				diagnostic tests and evaluations include a determination of visual acuity, a
				slit lamp examination and, when indicated, a dilated fundus
				examination.
25.4. Treatment is
				administered on an outpatient basis and consists of topical antibiotics,
				cycloplegics, and a pressure patch. For severe pain analgesics may be
				indicated.
25.5. The duration of
				care consists of daily visits up to 72 hours with a return to work within two
				days unless there are complications.
25.6. The anticipated outcome is full
				recovery.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-20 - Medical Management Of Claims, Guidelines For Impairment Evaluations, Evidence, And Ratings, And Ranges Of Permanent Partial Disability Awards › Section 85-20-26 - Treatment Guidelines: Corneal Foreign Body

Current through Register Vol. XLI, No. 28, July 12, 2024
26.1. Corneal foreign body generally occurs
				when striking stone; hot metal may perforate the cornea and enter the eye.
				Contaminated foreign bodies pose a risk for corneal ulcers or systemic
				toxicological effect.
26.2. The
				diagnostic criteria consists of pain which occurs either immediately after the
				injury or within the first twenty-four hours, accompanied by a sensation of
				something in the eye, and photophobia. The pain is aggravated by blinking or
				moving the eye. Vision may be affected if the foreign body is in the visual
				axis.
26.3. The appropriate
				diagnostic tests and examinations consist of a comprehensive examination,
				including determination of visual acuity, a slit lamp examination and dilated
				fundus examination when indicated to rule out intraocular foreign bodies. An
				orbital x-ray or CT scan may be indicated if there is a suspicion of ocular or
				orbital penetration.
26.4.
				Treatment is administered on an outpatient basis and consists of the following:
a. Removal of embedded foreign
				body;
b. Topical antibiotics,
				cycloplegics, and pressure patch;
c. Analgesics for the first several
				days;
d. Daily visits until the
				cornea is healed; and e. If a scar remains in the visual axis, corrective
				lenses or surgery may be required to attain optimal vision.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-20 - Medical Management Of Claims, Guidelines For Impairment Evaluations, Evidence, And Ratings, And Ranges Of Permanent Partial Disability Awards › Section 85-20-27 - Treatment Guidelines: Hyphema

Current through Register Vol. XLI, No. 28, July 12, 2024
27.1. Hyphema is bleeding within the anterior
				chamber of the eye, typically caused by a severe blunt trauma to the eye
				rupturing intraocular blood vessels. Hyphema may be associated with disruptions
				of the trabecular meshwork and lead to angle recession glaucoma. Early
				complications include elevated intraocular pressure causing blood staining of
				the cornea, vision loss, and most significantly, rebleeding which will occur in
				up to 30% of the cases within the third to fifth day. Rebleeding may cause
				marked elevation of intraocular pressure, corneal blood staining and visual
				loss. Late complications may include angle - recession glaucoma and cataract.
				Injured workers at considerable risk for complications include those with
				sickle cell or other coagulopathy.
27.2. Diagnostic criteria consist of a
				history of a blunt trauma to the eyes. The physical findings may include red
				blood cells visible within the anterior chamber, a layered clot filling the
				entire anterior chamber and/or intraocular pressure elevation.
27.3. The appropriate diagnostic tests and
				examinations are as follows:
a. Immediate
				referral to an opthalmologist as this is an ocular emergency;
b. A comprehensive examination by an
				ophthalmologist including a slit lamp exam, determination of the intraocular
				pressure, and a dilated fundus examination if possible;
c. Orbital x-rays may be indicated to rule
				out other orbital injuries; and
d.
				A platelet count and coagulation study as indicated as well as a sickle prep,
				and hemoglobin electrophoresis as indicated.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-20 - Medical Management Of Claims, Guidelines For Impairment Evaluations, Evidence, And Ratings, And Ranges Of Permanent Partial Disability Awards › Section 85-20-28 - Treatment Guidelines: Eyelid Laceration

Current through Register Vol. XLI, No. 28, July 12, 2024
28.1. Eyelid lacerations may occur from blunt
				injuries or from laceration by a sharp object. They may involve only skin,
				eyelid muscles, eyelid margin, and the lacrimal drainage system and may be
				associated with an orbital foreign body.
28.2. The diagnostic criteria consists of
				laceration and bleeding, which may be profuse.
28.3. The appropriate diagnostic tests and
				examinations consist of a comprehensive examination including a visual acuity
				and a slit lamp examination to rule out an additional injury. A dilated fundus
				examination may be conducted when indicated.
28.4. Appropriate treatment is as follows:
a. Outpatient treatment is appropriate for
				uncomplicated lacerations. Sutures are generally removed in one to two weeks
				and medication may include antibiotics and analgesics.
b. Inpatient treatment is appropriate for
				injuries involving the lacrimal drainage system or those penetrating the orbit.
				The surgical repair may or may not require general anesthesia. Intravenous
				antibiotics are often indicated. Depending on the severity of the injury and
				overall condition of the injured worker, a one to two day hospital stay may be
				required. Medications may include topical, oral or parenteral antibiotics and
				analgesics.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-20 - Medical Management Of Claims, Guidelines For Impairment Evaluations, Evidence, And Ratings, And Ranges Of Permanent Partial Disability Awards › Section 85-20-29 - Treatment Guidelines: Canalicular Laceration

Current through Register Vol. XLI, No. 28, July 12, 2024
29.1. Laceration in the medial eyelid may
				injure the upper or lower canaliculus or lacrimal sac, resulting in constant
				tearing or abscess in the lacrimal sac (dacryocystitis). The presence of an
				infection within the lacrimal system usually requires surgical
				repair.
29.2. The appropriate
				diagnostic criteria consists of a laceration in the medial eyelid. Any
				laceration to the punctum may include canalicular laceration. Tearing or bloody
				tears and laterally displaced punctum may be present.
29.3. The appropriate diagnostic tests and
				examinations consist of a comprehensive examination, including visual acuity,
				slit lamp, examination, dilated fundus examination and probing of the
				canaliculus. Orbital x-rays or CT scan is appropriate if a fracture or foreign
				body is suspected.
29.4.
				Appropriate treatment is as follows:
a.
				Outpatient treatment is appropriate for simple lacerations and repair.
				Treatment consists of surgical repair including stent placement and topical
				drops and oral antibiotics as indicated.
b. Inpatient treatment is appropriate for
				contaminated or complicated wounds. Treatment consists of the following:
1. Surgical repairing; may include complex
				reconstruction;
2. Antibiotics and
				topical medications as indicated; and
3. Lacrimal bypass surgery if repair is
				unsuccessful.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-20 - Medical Management Of Claims, Guidelines For Impairment Evaluations, Evidence, And Ratings, And Ranges Of Permanent Partial Disability Awards › Section 85-20-30 - Treatment Guidelines: Orbital Contusion

Current through Register Vol. XLI, No. 28, July 12, 2024
30.1. An orbital contusion is usually a
				result of blunt trauma causing swelling and ecchymosis of the orbit not
				associated with any fractures or significant lacerations.
30.2. The diagnostic criteria consists of a
				history of a blunt trauma to the ocular area, with progressive swelling of the
				lids, ptosis, proptosis of the eye and diplopia.
30.3. The appropriate diagnostic tests and
				examinations consist of:
a. Comprehensive
				examination, including an assessment of visual acuity, slit lamp examination,
				and a dilated fundus examination;
b. Orbital x-rays; and
c. CT scan may be indicated.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-20 - Medical Management Of Claims, Guidelines For Impairment Evaluations, Evidence, And Ratings, And Ranges Of Permanent Partial Disability Awards › Section 85-20-31 - Treatment Guidelines: Orbital Fracture

Current through Register Vol. XLI, No. 28, July 12, 2024
31.1. Fractures of the orbit may be indirect,
				resulting in a "blowout" of the orbital floor or medial wall, or direct
				involving fractures of the orbital rims.
31.2. The appropriate diagnostic criteria
				consists of a history of blunt trauma to the eye, usually by an object larger
				then the bony orbital opening. The eye may appear proptosis or enophthalmic.
				Ocular motility is usually diminished. There is usually numbness over the cheek
				due to injury to the infraorbital nerve. There may be a palpable fracture of
				the orbital rim. There may also be a fracture of the zygomatic arch.
31.3. The appropriate diagnostic tests and
				examinations are as follows:
a. A
				comprehensive examination by an ophthalmologist is necessary, including a
				visual acuity, slit lamp examination and dilated fundus examination;
b. X-ray of the orbits; and
c. Coronal CT scans.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-20 - Medical Management Of Claims, Guidelines For Impairment Evaluations, Evidence, And Ratings, And Ranges Of Permanent Partial Disability Awards › Section 85-20-32 - Treatment Guidelines: Corneoscleral Lacerations

Current through Register Vol. XLI, No. 28, July 12, 2024
32.1. Corneoscleral lacerations are
				potentially severe injuries resulting from sharp objects making forceful
				contact with the globe.
32.2. The
				appropriate diagnostic criteria consists of:
a. A detailed examination by an
				ophthalmologist including visual acuity, slit lamp exam, intraocular pressure
				and dilated fundus exam.
b. CT scan
				of orbits may be required.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-20 - Medical Management Of Claims, Guidelines For Impairment Evaluations, Evidence, And Ratings, And Ranges Of Permanent Partial Disability Awards › Section 85-20-33 - Treatment Guidelines: Chemical Ocular Injuries

Current through Register Vol. XLI, No. 28, July 12, 2024
33.1. Chemical injuries may result from an
				almost infinite variety of agents contacting the ocular surface, with the
				extent of the injury largely a function of the nature of the substance
				involved, how much ocular surface is involved, and duration of
				exposure.
33.2. The appropriate
				diagnostic criteria is as follows: A detailed examination is performed after
				copious irrigation (see treatment). It is vitally important to know the
				chemical causing the injury, its concentration and amount of exposure.
In alkali burns, the Hughes classification (grading or
				  corneal haziness and loss of blood vessels at limbus) is helpful in assessing
				  long term prognosis.
33.3.
				The appropriate treatment is as follows:
a.
				Acute phase (0 to 7 days).
1. Immediate
				copious irrigation using any nontoxic irrigating solution;
2. Detailed ophthalmologic exam, including pH
				level of eye secretions;
3. Topical
				steroids, antibiotic drops, topical ascorbate and cycloplegic agents;
4. Follow-up outpatient for 3
				weeks;
5. Immediate referral to
				ophthalmologist for alkaline burns; and
6. Monitoring for systemic effect of
				toxin.