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 85-20-6 - The Role of the Treating Physician

Current through Register Vol. XLI, No. 28, July 12, 2024
6.1. Each injured worker selects a treating
				physician of record who will treat the injured worker and be responsible for
				coordinating all subsequent health care. The treating physician of record may
				be a medical doctor, osteopath, podiatrist, or chiropractor. Any treating
				physician who is limited in number of treatments by another provision of this
				Rule shall, upon exhaustion of that limit, only seek reimbursement as a
				treating physician for services provided in intervals consistent with those of
				other treating physicians. The injured worker should not seek care from more
				than one provider without contacting the Commission, Insurance Commissioner,
				private carrier or self-insured employer, whichever is applicable, requesting
				the designation of a different attending physician, and having that request
				approved. Injured workers whose employer's or the employer's private carrier's
				managed care plans have been approved by the Commission or Insurance
				Commissioner, whichever is applicable, or who are covered by a managed care
				plan adopted by the Commission shall chose a treating physician offered under
				the applicable plan.
6.2. Whenever
				possible, the treating physician should use the least costly mode of treatment.
				This generally will require that outpatient services be used in lieu of
				inpatient care and the avoidance of referring injured workers to hospital
				emergency rooms for care that can be rendered in the office. The Commission,
				Insurance Commissioner, private carrier or self-insured employer, whichever is
				applicable, will approve payment for initial use of emergency room facilities
				and services such as routine dressings, routine tests, routine medications and
				routine local anesthesia. Subsequent use of the emergency room for services
				will not be approved without a statement from the physician explaining the
				necessity for the services rendered. Routine visits to the emergency room shall
				not be approved or reimbursed by the Commission, Insurance Commissioner,
				private carrier or self-insured employer, whichever is applicable.
6.3. Treating physicians should request
				referral of an injured workers who continues to report pain and dysfunction
				while showing no significant measurable or objective signs of improvement for a
				Permanent Partial Disability evaluation. Such injured workers may also be
				discharged or referred to a different, appropriate specialty for evaluation and
				possible modification of treatment.
6.4. When the treating physician finds the
				injured worker to be at maximum medical improvement, the treating physician may
				provide an impairment rating pursuant to applicable Guidelines for the injured
				worker. If the rating exceeds fifteen percent (15%), the Commission, Insurance
				Commissioner, private carrier or self-insured employer, whichever is
				applicable, may accept or reject the rating and may order an independent
				evaluation of the injured worker. The treating physician may also report a
				finding of Maximum Medical Improvement without making an impairment rating,
				reported on Form WC-219a, "Notice of Maximum Medical Improvement."
6.5. The treating physician of record shall
				provide a treatment plan for the medical care being considered in narrative
				form as set forth in section 3.11 of this Rule.
6.6. It is the responsibility of the treating
				physician to notify the Commission, Insurance Commissioner, private carrier or
				self-insured employer, whichever is applicable, of the injured worker's most
				accurate and current condition. The initial diagnosis reported when a claim is
				filed often requires updating based on diagnostic tests and clinical objective
				findings. Changes, additions and revisions of the injured worker's condition
				must be reported using the applicable Commission, Insurance Commissioner,
				private carrier or self-insured employer, whichever is applicable, form. All
				changes related to a diagnosis code shall submitted to the Commission,
				Insurance Commissioner, private carrier or self-insured employer, whichever is
				applicable, and must be approved by the Commission, Insurance Commissioner,
				private carrier or self-insured employer, whichever is applicable,, unless the
				new diagnosis is otherwise accepted by the Commission, Insurance Commissioner,
				private carrier or self-insured employer, whichever is applicable, as being
				causally related to the compensable injury. Bills submitted for treatment that
				is clearly unrelated to the compensable diagnosis shall be denied and may serve
				as evidence of abuse under W. Va. Code §
									23-4-3c
				and/or fraud under W. Va. Code §
									61-3-24g.
				The Commission, Insurance Commissioner, private carrier or self-insured
				employer, whichever is applicable, may, in its sole discretion, recognize and
				identify the change, addition, or revision as a compensable
				condition.
6.7. Injured workers
				must request authorization from the Commission, Insurance Commissioner, private
				carrier or self-insured employer, whichever is applicable, to change the
				treating physician of record in their claim. This rule does not apply in the
				following cases:
a. Care transferred after
				initial emergency or first aid treatment if done so within 30 days of the date
				of injury;
b. Care transferred to a
				specialist by the original treating physician; or c. Care where an unforeseen
				emergency develops which requires special facilities and skills are not
				available to the treating physician or hospital.