reglab/statecodes huggingface dataset:
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › MEDICAL COVERAGE DECISIONS › Section 296-20-02704 - What criteria does the director or director's designee use to make medical coverage decisions?

Current through Register Vol. 24-14, July 15, 2024
(1) In making
				medical coverage decisions, the director or the director's designee considers
				information from a variety of sources. These sources include, but are not
				limited to:
Scientific evidence;
National and community-based opinions;
Informal syntheses of provider opinion;
Experience of the department and other entities;
Regulatory status.
Because of the unique nature of each health care service, the
				  type, quantity and quality of the information available for review may vary.
				  The director or director's designee weighs the quality of the available
				  evidence in making medical coverage decisions.
(2) Scientific evidence.
(a) "Scientific evidence" includes reports
				and studies published in peer-reviewed scientific and clinical literature. The
				director or the director's designee will consider the nature and quality of the
				study, its methodology and rigorousness of design, as well as the quality of
				the journal in which the study was published.
For treatment services, studies addressing safety, efficacy,
				  and effectiveness of the treatment or procedure for its intended use will be
				  considered.
For diagnostic devices or procedures, studies addressing
				  safety, technical capacity, accuracy or utility of the device or procedure for
				  its intended use will be considered.
(b) The greatest weight will be given to the
				most rigorously designed studies and on those well-designed studies that are
				reproducible. The strength of the design will depend on such scientifically
				accepted methodological principles as randomization, blinding, appropriateness
				of outcomes, spectrum of cases and controls, appropriate power to detect
				differences, magnitude and significance of effect. Additional consideration
				will be given to those studies that focus on sustained health and functional
				outcomes of workers with occupational conditions rather than unsustained
				clinical improvements.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › MEDICAL COVERAGE DECISIONS › Section 296-20-02705 - What are treatment and diagnostic guidelines and how are they related to medical coverage decisions?

Current through Register Vol. 24-14, July 15, 2024
(1)
				Treatment and diagnostic guidelines are developed by the department for the
				diagnosis or treatment of accepted conditions. These guidelines are developed
				to give providers a range of the many treatment or diagnostic options available
				for a particular medical condition. Treatment and diagnostic guidelines are a
				combination of the best available scientific evidence and a consensus of expert
				opinion.
(2) The department may
				develop treatment or diagnostic guidelines to improve outcomes for workers
				receiving covered health services. As appropriate to the subject matter, the
				department may develop these guidelines in collaboration with the following
				committees:
. The industrial insurance medical advisory committee;
. The industrial insurance chiropractic advisory
				  committee.
. The Washington state pharmacy and therapeutics
				  committee.
. The Washington state health technology assessment clinical
				  committee.
(3) In the process of
				implementing these guidelines, the department may find it necessary to make a
				formal medical coverage decision on one or more of the treatment or diagnostic
				options. The department, not the advisory committees, is responsible for
				implementing treatment guidelines and for making coverage decisions that result
				from such implementation.
(4)
				Network providers are required to follow the department's evidence-based
				coverage decisions, treatment guidelines, and policies.
Statutory Authority:
					 RCW
					 51.36.010,
					 51.04.020, and
					 51.04.030. 12-23-020, §
					 296-20-02705, filed 11/13/12, effective 12/14/12. Statutory Authority: 2007 c
					 282, RCW 51.04.02 [51.04.020], 51.04.030. 08-02-020, § 296-20-02705, filed
					 12/21/07, effective 1/21/08. Statutory Authority:
					 RCW
					  51.04.020,
					 70.14.050. 04-08-040, §
					 296-20-02705, filed 3/30/04, effective 5/1/04. Statutory Authority:
					 RCW
					  51.04.020 and
					 51.04.030. 00-01-037, §
					 296-20-02705, filed 12/7/99, effective
					 1/8/00.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › MEDICAL COVERAGE DECISIONS › Section 296-20-02850 - When may the department cover controversial, obsolete, investigational or experimental treatment?

Current through Register Vol. 24-14, July 15, 2024
(1) The
				department or self-insurer will not authorize nor pay for treatment measures of
				a controversial, obsolete, investigational or experimental nature. (See WAC
				296-20-03002.) Under certain
				conditions, the director or the director's designee may determine that such
				treatment is appropriate. In making such a decision, the director or director's
				designee will consider factors including, but not limited to, the following:
(a) Scientific studies investigating the
				safety and efficacy of the treatment are incomplete, or if completed, have
				conflicting conclusions, and:
Preliminary data indicate the treatment or diagnostic
				  procedure or device has improved net health and functional outcomes; and
No alternative treatment or diagnostic is available;
				  or
(b) The treatment or
				diagnostic procedure or device is prescribed as part of:
A controlled, clinical trial that has been reviewed and
				  approved by an institutional review board that was established in accordance
				  with the federal Department of Health and Human Services (DHHS) regulations ( 45
				  C.F.R. Part 46  consistent with the purposes of this chapter, and as now or
				  hereafter amended); and
For medical devices not yet cleared for marketing, the
				  clinical evaluation has an approved investigational device exemption (IDE) in
				  accordance with the federal Food and Drug Administration (FDA) regulations (21
				  C.F.R. Parts 50, 56, and 812 consistent with the purposes of this chapter, and
				  as now or hereafter amended); and
For drugs not yet cleared for marketing, the clinical
				  evaluation has been approved in accordance with the federal Food and Drug
				  Administration (FDA) regulations ( 21 C.F.R. Part 312  consistent with the
				  purposes of this chapter, and as now or hereafter amended); or
(c) The usually indicated
				procedure or diagnostic test would likely be harmful for the patient because of
				other unrelated conditions.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › TREATMENT AUTHORIZATION REQUIREMENTS › Section 296-20-03001 - Treatment requiring authorization

Current through Register Vol. 24-14, July 15, 2024
Certain treatment procedures require authorization by the
				  department or self-insurer. Requests for authorization must include a statement
				  of: The condition(s) diagnosed; the current federally adopted ICD-CM codes;
				  their relationship, if any, to the industrial injury/exposure; an outline of
				  the proposed treatment program, its length and components, procedure codes, and
				  expected prognosis; and an estimate of when treatment would be concluded and
				  condition stable.
(1) Office calls in
				excess of the first twenty visits or sixty days whichever occurs
				first.
(2) The department may
				designate those inpatient hospital admissions that require prior
				authorization.
(3) X ray and radium
				therapy.
(4) Diagnostic studies
				other than routine X-ray and blood or urinalysis laboratory studies.
(5) Myelogram in nonemergent cases.
(6) Physical therapy treatment beyond initial
				twelve treatments as outlined in chapters 296-21, 296-23, and 296-23A
				WAC.
(7) Diagnostic or therapeutic
				injections that include, but are not limited to:
(a) Therapeutic subarachnoid, epidural, or
				caudal injections for chronic pain;
(b) Diagnostic facet injections;
(c) Sacroiliac joint injections for chronic
				pain;
(d) Intra-muscular and
				trigger point injections of steroids and other nonscheduled medications are
				limited to three injections per patient. The attending doctor must submit
				justification for an additional three injections if indicated with a maximum of
				six injections to be authorized for any one patient.
Refer to fee schedule payment policies and coverage decisions
				  for authorization criteria.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › TREATMENT AUTHORIZATION REQUIREMENTS › Section 296-20-03002 - Treatment not authorized

Current through Register Vol. 24-14, July 15, 2024
The department or self-insurer will not allow nor pay for
				  following treatment:
(1) Use of
				diapulse, thermatic (standard model only), spectrowave and superpulse machines
				on workers entitled to benefits under the Industrial Insurance Act.
(2) Iontophoresis; prolotherapy; injections
				of colchicine; injections of fibrosing or sclerosing agents; and injections of
				substances other than anesthetic or contrast into the subarachnoid space
				(intra-thecal injections).
(3)
				Treatment to improve or maintain general health (i.e., prescriptions and/or
				injection of vitamins or referrals to special programs such as health spas,
				swim programs, exercise programs, athletic-fitness clubs, diet programs, social
				counseling).
(4) Continued
				treatment beyond stabilization of the industrial condition(s), i.e.,
				maintenance care, except where necessary to monitor prescription of medication
				necessary to maintain stabilization i.e., anti-convulsive, anti-spasmodic,
				etc.
(5) After consultation and
				advice to the department or self-insurer, any treatment measure deemed to be
				dangerous or inappropriate for the injured worker in question.
(6) Treatment measures of an unusual,
				controversial, obsolete, or experimental nature (see WAC
				296-20-045). Under certain conditions, treatment in this category may be approved by the
				department or self-insurer. Approval must be obtained prior to treatment.
				Requests must contain a description of the treatment, reason for the request
				with benefits and results expected.
(7) Therapeutic medial branch block
				injections, therapeutic intradiscal injections, and therapeutic facet
				injections of the spine.
(8)
				Transcutaneous, interferential, and percutaneous nerve stimulators used in the
				home setting, and all associated supplies and equipment.
Statutory Authority:
					 RCW
					  70.14.110,
					 51.04.020, and
					 51.04.030. 12-12-059, §
					 296-20-03002, filed 6/5/12, effective 7/6/12. Statutory Authority:
					 RCW
					  70.14.120,
					 51.04.020,
					 51.04.030. 09-20-040, §
					 296-20-03002, filed 9/30/09, effective 11/1/09. Statutory Authority:
					 RCW
					  51.04.020,
					 51.04.030. 06-15-110, §
					 296-20-03002, filed 7/18/06, effective 8/18/06. Statutory Authority:
					 RCW
					  51.04.020(4) and
					 51.04.030. 86-06-032 (Order
					 86-19), § 296-20-03002, filed 2/28/86, effective 4/1/86; 83-16-066 (Order
					 83-23), § 296-20-03002, filed 8/2/83. Statutory Authority:
					 RCW
					  51.04.020(4),
					 51.04.030, and
					 51.16.120(3).
					 81-24-041 (Order 81-28), § 296-20-03002, filed 11/30/81, effective 1/1/82;
					 81-01-100 (Order 80-29), § 296-20-03002, filed 12/23/80, effective 3/1/81;
					 Order 76-34, § 296-20-03002, filed 11/24/76, effective
					 1/1/77.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › TREATMENT AUTHORIZATION REQUIREMENTS › Section 296-20-03004 - Chemonucleolysis

Current through Register Vol. 24-14, July 15, 2024
Chymopapain injections may be authorized in the treatment of
				  lumbar disc disease under the following limitations and criteria:
(1) Only physicians (a) who routinely care
				for patients with herniated lumbar intervertebral discs, (b) who are qualified
				by training and experience to diagnose lumbar disc disease and to perform
				laminectomy, discectomy or other spinal procedures, (c) who have received
				specialized training in chemonucleolysis, may administer the procedure for
				industrial injured workers covered under state industrial insurance fund or
				self-insurance.
(2)
				Preadministration work-up shall include but is not limited to (a) a concurring
				opinion from a physician familiar with the procedure and qualified by training
				and experience to diagnose and treat lumbar disc disease, (b) diagnostic
				studies indicative of level of disc herniation i.e., myelogram, a high
				resolution CT scan, discogram, etc., (c) other diagnostic studies including
				sedimentation rate (anaphylaxis has occurred primarily in females with
				sedimentation rates in excess of 20 mm per hour) as indicated for the
				individual patient.
(3) Procedure
				will be authorized (a) one time only in the treatment life of any given
				patient, (b) maximum of two levels per patient (Generally only one level will
				be authorized. Indications for a second level are infrequent. However,
				authorization may be granted if diagnostic studies and/or concurring opinion so
				indicates.), (c) only for patients who have had no previous lumbar surgery at
				that level.
(4) Procedure must be
				carried out in hospital setting under radiographic or fluoroscopic control,
				with a permanent X-ray record maintained.
(5)
Prior authorization from the
				department or the self-insurer must be obtained before procedure is
				scheduled.
(6) These rules
				were formulated based upon the recommendations of the Federal Food and Drug
				Administration, the drug manufacturer, and the industrial insurance committee
				of the Washington state medical association.
Statutory Authority:
					 RCW
					 51.04.020(4) and
					 51.04.030. 83-16-066 (Order
					 83-23), § 296-20-03004, filed
					 8/2/83.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › MEDICATION RULES › Section 296-20-03005 - Inoculation or immunological treatment for exposure to infectious occupational disease

Current through Register Vol. 24-14, July 15, 2024
Authorization for inoculation or other immunological
				  treatment for occupational disease shall be given only in cases in which a work
				  related activity has resulted in probable exposure of the worker to a potential
				  infectious occupational disease. In no case shall such inoculation or
				  immunological treatment be authorized until such time as a work related
				  activity has resulted in such probable exposure. Inoculation or other treatment
				  required as a condition for employment or otherwise obtained prior to the
				  worker's performing a work related activity resulting in probable exposure to
				  an occupational disease shall not be authorized. For purposes of this section,
				  probable exposure is an incident which gives rise to a clear and immediate
				  likelihood of contracting an occupational disease process.
Statutory Authority:
					 RCW
					 51.04.020(4),
					 51.04.030 and
					 51.36.010. 86-18-025 (Order
					 86-34), § 296-20-03005, filed 8/27/86, effective
					 11/1/86.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › MEDICATION RULES › Section 296-20-03010 - What are the general principles the department uses to determine drug coverage?

Current through Register Vol. 24-14, July 15, 2024
In general, the department evaluates data on safety, health
				  outcomes and cost-effectiveness for coverage. The department or self-insurer
				  considers payment for drugs, including biologics and controlled substances,
				  when:
. The drug is used to treat the industrial injury or
				  occupational disease accepted under the claim; and
. The drug is prescribed consistent with the department's
				  rules, guidelines and coverage decisions, and either:
- The drug is approved by the Food and Drug Administration
				  (FDA) for that condition and prescribed in accordance with labeling, or is
				  licensed by a regulatory entity similar to the FDA for workers who reside
				  outside the United States; or
- If the drug is prescribed off-label, the use is supported
				  by published scientific evidence of safety and effectiveness from high quality
				  randomized trials (see WAC
				  296-20-02704). Off-label is
				  defined as use of a FDA-approved drug for an indication which has not received
				  FDA approval or is otherwise not consistent with the drug
				  labeling.
Statutory Authority:
					 RCW
					 51.04.020 and
					 51.04.030. 13-12-024, §
					 296-20-03010, filed 5/28/13, effective 7/1/13; 00-01-040, § 296-20-03010,
					 filed 12/7/99, effective 1/20/00.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › MEDICATION RULES › Section 296-20-03011 - What general limitations are in place for drugs?

Current through Register Vol. 24-14, July 15, 2024
(1)
Amount dispensed.
The
				department or self-insurer will pay for no more than a thirty-day supply of a
				drug dispensed at any one time except in pension cases (see subsection (6) of
				this section) and claims that are held open for life-sustaining treatment. In
				these cases, up to a ninety-day supply of the drug is payable when:
* Coverage has been authorized; and
* The drug is not a controlled substance; and
* The drug is obtained through a designated provider.
(2)
Over-the-counter
				drugs.
Prescriptions for over-the-counter items may be paid. Special
				compounding fees for over-the-counter items are not payable.
(3)
Generic drugs or interchangeable
				biological products.
Generic drugs or interchangeable biological
				products must be dispensed when available unless the provider specifically
				indicates that substitution is not permitted.
(4)
Evidence-based prescription drug
				program.
In accordance with
				RCW
				 70.14.050, the department in cooperation with
				other state agencies may develop a preferred drug list. Any pharmacist filling
				a prescription for participating state purchased health care programs shall
				dispense the preferred drug in accordance with the endorsing practitioner
				therapeutic interchange program (see WAC
				182-50-200).
(5)
Prescriptions for unrelated
				medical conditions.
The department or self-insurer may consider
				temporary coverage of prescriptions for conditions not related to the
				industrial injury when such conditions are retarding recovery. Any treatment
				for such conditions must have prior authorization per WAC
				296-20-055. This would apply to
				any prescription for such conditions even when the endorsing practitioner
				indicates "dispense as written."
(6)
Pension cases.
When the worker is placed on a
				pension, the department or self-insurer may pay, at the sole discretion of the
				supervisor of industrial insurance, for only those drugs authorized for
				continued medical treatment of previously accepted conditions:
(a)  Coverage must be authorized before the
				treatment is rendered.
(b) 
				Controlled substances used to treat continuing pain resulting from an
				industrial injury or occupational disease are not payable.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › MEDICATION RULES › Section 296-20-03012 - Where can I find the department's outpatient drug coverage decisions?

Current through Register Vol. 24-14, July 15, 2024
The department's outpatient drug coverage decisions are
				  contained in the department's formulary, as developed by the department, in
				  collaboration with the Washington state pharmacy and therapeutics committee and
				  the industrial insurance medical advisory committee.
In the formulary, drugs are listed in the following
				  categories:
.
Allowed
Drugs used routinely for treating accepted industrial
				  injuries and occupational diseases, including those on the preferred drug
				  list.
Example: Preferred nonsteroidal anti-inflammatory drugs
				  during the acute phase of treatment for the industrial injury.
.
Prior authorization required
Drugs used routinely to treat conditions not normally
				  accepted as work related injuries, drugs which are used to treat unrelated
				  conditions retarding recovery from the accepted condition on the claim, and
				  drugs for which less expensive alternatives exist.
Example: All drugs to treat hypertension require prior
				  authorization because hypertension is not normally an accepted industrial
				  condition. In addition, nonendorsing practitioners must obtain prior
				  authorization for a nonpreferred drug when the category of drugs has a
				  preferred drug.
.
Denied
Drugs not normally used for treating industrial injuries or
				  not normally dispensed by outpatient pharmacies.
Example: Most hormones, most nutritional
				  supplements.
Statutory Authority:
					 RCW
					 51.04.020 and
					 51.04.030. 13-12-024, §
					 296-20-03012, filed 5/28/13, effective 7/1/13. Statutory Authority:
					 RCW
					  51.04.020,
					 70.14.050. 04-08-040, §
					 296-20-03012, filed 3/30/04, effective 5/1/04. Statutory Authority:
					 RCW
					 51.04.020 and
					 51.04.030. 00-01-040, §
					 296-20-03012, filed 12/7/99, effective
					 1/20/00.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › MEDICATION RULES › Section 296-20-03013 - Will the department or self-insurer pay for a denied outpatient drug in special circumstances?

Current through Register Vol. 24-14, July 15, 2024
Some of the drugs that are routinely denied may be covered in
				  special circumstances. Requests for coverage under special circumstances
				  require authorization prior to treatment. Examples of drugs that may be covered
				  in special circumstances include:
Drugs and medications to treat unrelated conditions when
				  retarding recovery;
Special treatments for unique catastrophic injuries.
The department may require written documentation to support
				  the request.
Statutory Authority:
					 RCW
					 51.04.020 and
					 51.04.030. 00-01-040, §
					 296-20-03013, filed 12/7/99, effective
					 1/20/00.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › MEDICATION RULES › Section 296-20-03014 - Which drugs have specific limitations?

Current through Register Vol. 24-14, July 15, 2024
(1)
Injectables.
Prescriptions
				for injectable opioids or other analgesics, sedatives, antihistamines,
				tranquilizers, psychotropics, vitamins, minerals, food supplements, and
				hormones are not covered.
Exceptions: The department or self-insurer covers injectable
				  medications under the following circumstances.
(a) Indicated injectable drugs for the
				following:
Inpatients; or
During emergency treatment of a life-threatening
				  condition/injury; or
During outpatient treatment of severe soft tissue injuries,
				  burns or fractures when needed for dressing or cast changes; or
During the perioperative period and the postoperative period,
				  not to exceed forty-eight hours from the time of discharge.
(b) Prescriptions of injectable insulin,
				heparin, anti-migraine medications, or impotency treatment, when proper and
				necessary.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › MEDICATION RULES › Section 296-20-03015 - What steps may the department or self-insurer take when concerned about the amount or appropriateness of drugs prescribed for the injured worker?

Current through Register Vol. 24-14, July 15, 2024
(1) The department
				or self-insurer may take any or all of the following steps when concerned about
				the amount or appropriateness of drugs the worker is receiving:
. Notify the provider of concerns regarding the drugs such as
				  interactions, adverse reactions, or prescriptions by other providers;
. Notify the provider when opioid prescribing is not in
				  compliance with the department of health's (DOH) pain management rules, the
				  department of labor and industries' (L&I) rules, the agency medical
				  directors' group's interagency guideline on opioid dosing for chronic noncancer
				  pain or L&I's guideline for prescribing opioids to treat pain in injured
				  workers;
. Require that the provider send a treatment plan addressing
				  the drug concerns;
. Request a consultation from an appropriate
				  specialist;
. Request that the provider consider reducing the dose or
				  discontinuing the drug and provide information on chemical dependency programs,
				  if indicated;
. Limit the payment for drugs to one prescribing
				  provider.
(2) If the provider or
				worker does not comply with these requests, the department or self-insurer may
				discontinue payment for the drug after adequate prior notification has been
				given to the worker and the provider.
(3) If the probability of imminent harm to
				the worker is high, as determined by the department's medical director,
				associate medical director or medical consultants, the department or
				self-insurer may require that the worker transfer care to another network
				provider.
(4) Other corrective
				actions may be taken in accordance with WAC
				296-20-01100, Risk of
				harm.
Statutory Authority:
					 RCW
					 51.04.020 and
					 51.04.030. 13-12-024, §
					 296-20-03015, filed 5/28/13, effective 7/1/13; 00-01-040, § 296-20-03015,
					 filed 12/7/99, effective 1/20/00.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › MEDICATION RULES › Section 296-20-03017 - What information is needed for prescriptions and the physician's record?

Current through Register Vol. 24-14, July 15, 2024
Prescriptions must include the department authorized provider
				  number for the prescribing physician and the physician's signature. The
				  physician's record must contain the name and reason for the medication, the
				  dosage, quantity prescribed and/or dispensed, the route of administration, the
				  frequency, the starting and stopping dates, the expected outcome of treatment,
				  and any adverse effects that occur. Please refer to WAC 296-20-03021 and
				  296-20-03022 for additional documentation requirements when treating chronic,
				  noncancer pain.
Statutory Authority:
					 RCW
					 51.04.020 and
					 51.04.030. 00-01-040, §
					 296-20-03017, filed 12/7/99, effective
					 1/20/00.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › MEDICATION RULES › Section 296-20-03018 - What inpatient drugs are covered?

Current through Register Vol. 24-14, July 15, 2024
In general, the department or self-insured employer pays for
				  most drugs in an inpatient hospital setting. Please see WAC
				  296-20-075,
				  Hospitalization.
Statutory Authority:
					 RCW
					 51.04.020 and
					 51.04.030. 00-01-040, §
					 296-20-03018, filed 12/7/99, effective
					 1/20/00.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › OPIOIDS FOR NONCANCER PAIN › Section 296-20-03030 - Definitions associated with opioid authorization and payment

Current through Register Vol. 24-14, July 15, 2024
(1) Acute pain -
				Self-limiting pain that lasts from a few days to up to six weeks following an
				industrial injury or surgery.
(2)
				Catastrophic injury - A severe injury from which recovery of physical function
				is not expected, such as a spinal cord injury.
(3) Clinically meaningful improvement in
				function - Improvement in function of at least thirty percent as compared to
				baseline or in response to a dose change. Function can be measured using the
				two item graded chronic pain scale or other validated tools such as those
				referenced in the most current agency medical directors' group's interagency
				guideline on opioid dosing for chronic noncancer pain.
(4) Clinically meaningful improvement in pain
				- Improvement in pain intensity of at least thirty percent as compared to
				baseline or in response to a dose change. Pain can be measured using the two
				item graded chronic pain scale or other validated tools such as those
				referenced in the most current agency medical directors' group's interagency
				guideline on opioid dosing for chronic noncancer pain.
(5) Chronic noncancer pain - Continuous or
				intermittent pain arising from a noncancerous condition, injury or surgery and
				lasting longer than three months.
(6) Morphine equivalent dose - Conversion of
				various opioids to an equivalent morphine dose by using the most current
				recognized conversion tables, such as the agency medical directors' group's
				dose calculator.
(7) Step 1 taper -
				Discontinuing opioids via a gradual dose reduction of approximately ten percent
				of the original dose per week in a community care setting.
(8) Step 2 taper - Detoxification through a
				licensed chemical dependency center and/or discontinuing opioids through a
				structured intensive multidisciplinary program (see WAC
				296-20-12055 through
				296-20-12095).
Statutory Authority:
					 RCW
					 51.04.020 and
					 51.04.030. 13-12-024, §
					 296-20-03030, filed 5/28/13, effective
					 7/1/13.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › OPIOIDS FOR NONCANCER PAIN › Section 296-20-03035 - Checking the prescription monitoring program data base

Current through Register Vol. 24-14, July 15, 2024
Checking the prescription monitoring program is recommended
				  before prescribing opioids for new injuries. Providers must check the
				  prescription monitoring program data base, if available, and document before
				  prescribing opioids in the subacute phase and repeat during chronic opioid
				  therapy at intervals according to the worker's risk category as described in
				  the agency medical directors' group's guideline.
Any provider performing a preoperative evaluation for
				  elective surgery in workers on chronic opioid therapy should also check the
				  prescription monitoring program data base and document as part of a treatment
				  plan for post-surgical pain management.
Statutory Authority:
					 RCW
					 51.04.020 and
					 51.04.030. 13-12-024, §
					 296-20-03035, filed 5/28/13, effective
					 7/1/13.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › OPIOIDS FOR NONCANCER PAIN › Section 296-20-03040 - Administering urine drug testing

Current through Register Vol. 24-14, July 15, 2024
Providers must administer a urine drug test and document
				  results during the subacute phase and repeat at intervals according to the
				  worker's risk category as described in the agency medical directors' group's
				  guideline if prescribing chronic opioid therapy. The department or self-insurer
				  may deny additional payment for urine drug testing when opioid coverage is
				  denied.
Statutory Authority:
					 RCW
					 51.04.020 and
					 51.04.030. 13-12-024, §
					 296-20-03040, filed 5/28/13, effective
					 7/1/13.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › OPIOIDS FOR NONCANCER PAIN › Section 296-20-03045 - Tracking function and pain

Current through Register Vol. 24-14, July 15, 2024
When prescribing opioids, providers must use validated
				  instruments to track and document the worker's function and pain status during
				  the acute and subacute phase and routinely, at least every ninety days, to
				  monitor the worker's status and response to chronic opioid
				  therapy.
Statutory Authority:
					 RCW
					 51.04.020 and
					 51.04.030. 13-12-024, §
					 296-20-03045, filed 5/28/13, effective
					 7/1/13.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › OPIOIDS FOR NONCANCER PAIN › Section 296-20-03050 - Preinjury opioid use

Current through Register Vol. 24-14, July 15, 2024
The department or self-insurer is not responsible for the
				  continuation of preinjury opioid use or any adverse outcomes which may result.
				  For workers with preinjury chronic opioid therapy, payment for opioids beyond
				  the acute phase will not be authorized except:
. For catastrophic injuries (see WAC
				  296-20-03059); and
. For severe injuries, coverage may be extended through the
				  subacute phase.
Statutory Authority:
					 RCW
					 51.04.020 and
					 51.04.030. 13-12-024, §
					 296-20-03050, filed 5/28/13, effective
					 7/1/13.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › OPIOIDS FOR NONCANCER PAIN › Section 296-20-03055 - Opioid authorization requirement for the acute phase (0-6 weeks)

Current through Register Vol. 24-14, July 15, 2024
The department or self-insurer may cover opioids for up to
				  six weeks when prescribed to treat pain from the acute industrial injury or
				  after an authorized surgery. Providers must obtain and document the worker's
				  baseline function and pain measurements during the acute phase if planning to
				  prescribe opioids beyond this phase.
Statutory Authority:
					 RCW
					 51.04.020 and
					 51.04.030. 13-12-024, §
					 296-20-03055, filed 5/28/13, effective
					 7/1/13.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › OPIOIDS FOR NONCANCER PAIN › Section 296-20-03056 - Opioid authorization requirement for the subacute phase (6-12 weeks)

Current through Register Vol. 24-14, July 15, 2024
Before the department or self-insurer authorizes payment for
				  opioids beyond the acute phase, the provider must perform and document the
				  following:
. Verify that the worker had clinically meaningful
				  improvement in function and pain with the use of opioids in the acute
				  phase.
. If indicated, use a validated instrument to screen the
				  worker for comorbid psychiatric conditions (e.g., depression, anxiety, or post
				  traumatic stress disorder) which may impact the response to opioid
				  treatment.
. Verify that the worker has no contraindication to the use
				  of opioids.
. Access the state's prescription monitoring program data
				  base, if available, to ensure that the controlled substance history is
				  consistent with the prescribing record and the worker's report.
. Use a validated screening instrument to verify the absence
				  of a current substance use disorder (excluding nicotine) or a history of opioid
				  use disorder.
. Administer a baseline urine drug test to verify the absence
				  of cocaine, amphetamines, alcohol, and nonprescribed opioids.
. Verify that the worker has no evidence of or is not at high
				  risk for serious adverse outcomes from opioid use.
Statutory Authority:
					 RCW
					 51.04.020 and
					 51.04.030. 13-12-024, §
					 296-20-03056, filed 5/28/13, effective
					 7/1/13.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › OPIOIDS FOR NONCANCER PAIN › Section 296-20-03057 - Opioid authorization requirement for the chronic phase ([Greater than] 12 weeks)

Current through Register Vol. 24-14, July 15, 2024
Before the department or self-insurer authorizes payment for
				  opioids beyond the subacute phase, the provider must perform, verify, and
				  document the following best practices:
. Clinically meaningful improvement in function has been
				  established with opioid use in the acute or subacute phase. If the opioid dose
				  is increased, clinically meaningful improvement in function must be
				  demonstrated in response to the dose change. Effective chronic opioid therapy
				  should result in improved work capacity and/or the ability to progress in
				  vocational retraining; and
. Reasonable alternatives to opioids have been tried and have
				  failed; and
. The worker and the provider have signed a pain treatment
				  agreement; and
. A consultation with a pain management specialist must take
				  place before the worker's dose is increased above 120mg/d morphine equivalent
				  or consistent with exceptions in DOH's pain management rules. Additional
				  appropriate consultations are recommended if the worker has a comorbid
				  substance use or poorly controlled mental health disorder; and
. The worker has no contraindication to the use of opioids
				  including, but not limited to, current substance use disorders (excluding
				  nicotine) or history of opioid use disorder; and
. The worker has no evidence of or is not at high risk for
				  having serious adverse outcomes from opioid use; and
. The worker has no pattern of recurrent (more than one)
				  aberrant behavior identified by the prescription monitoring program data base,
				  urine drug testing, or other source; and
. A time-limited treatment plan that demonstrates how chronic
				  opioid therapy is likely to improve the worker's work capacity and/or the
				  ability to progress in vocational retraining (e.g., work hardening, vocational
				  services).
Statutory Authority:
					 RCW
					 51.04.020 and
					 51.04.030. 13-12-024, §
					 296-20-03057, filed 5/28/13, effective
					 7/1/13.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › OPIOIDS FOR NONCANCER PAIN › Section 296-20-03058 - Opioid authorization requirement for ongoing chronic opioid therapy

Current through Register Vol. 24-14, July 15, 2024
Before the department or self-insurer authorizes continued
				  payment for chronic opioid therapy, the provider must routinely, at least every
				  ninety days or more frequently, according to the worker's risk, review the
				  effects of opioids to determine whether therapy should continue and document
				  the following best practices:
. Clinically meaningful improvement in function or pain
				  interference with function score of <= 4 on the two item graded chronic pain
				  scale is maintained with stable dosing. If opioid dose is increased, clinically
				  meaningful improvement in function must be demonstrated in response to the dose
				  change; and
. A current signed pain treatment agreement; and
. The worker has no contraindication to the use of opioids
				  including, but not limited to, current substance use disorders (excluding
				  nicotine) or a history of opioid use disorder; and
. The worker has no evidence of or is not at high risk for
				  serious adverse outcomes from opioid use; and
. A consultation with a pain management specialist must take
				  place before the worker's dose is increased above 120mg/d morphine equivalent
				  dose or consistent with exceptions in DOH's pain management rules. Additional
				  appropriate consultations are recommended if the worker has a comorbid
				  substance use or poorly controlled mental health disorder; and
. The worker has no pattern of recurrent (more than one)
				  aberrant behavior identified by the prescription monitoring program data base,
				  urine drug testing or other source.
Workers receiving chronic opioid therapy should be managed by
				  a single prescribing provider. If the prescribing provider is unavailable, then
				  refills should be addressed by the covering provider and allowed on a limited
				  basis only. See WAC
				  296-20-03060, Episodic care for
				  pain, regarding unscheduled visits to emergency departments or urgent care
				  facilities for pain management.
Statutory Authority:
					 RCW
					 51.04.020 and
					 51.04.030. 13-12-024, §
					 296-20-03058, filed 5/28/13, effective
					 7/1/13.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › OPIOIDS FOR NONCANCER PAIN › Section 296-20-03059 - Opioid authorization requirement for catastrophic injuries

Current through Register Vol. 24-14, July 15, 2024
Before the department or self-insurer authorizes payment for
				  chronic opioid therapy for a catastrophic injury (see WAC
				  296-20-03030 for the definition
				  of catastrophic injury), the provider must perform, verify, and document the
				  following:
. A current signed pain treatment agreement; and
. A consultation with a pain management specialist must take
				  place before the worker's dose is increased above 120mg/d morphine equivalent
				  dose or consistent with exceptions in DOH's pain management rules; and
. The worker has no contraindication to the use of opioids
				  including, but not limited to, current substance use disorders (excluding
				  nicotine) or a history of opioid use disorder; and
. The dose is stable and the worker has no evidence of or is
				  not at high risk for serious adverse outcomes from opioid use; and
. The worker has no pattern of recurrent (more than one)
				  aberrant behavior identified by the prescription monitoring program data base,
				  urine drug testing or other source.
Catastrophic injuries are exempt from the requirement of
				  clinically meaningful improvement in function with opioid
				  use.
Statutory Authority:
					 RCW
					 51.04.020 and
					 51.04.030. 13-12-024, §
					 296-20-03059, filed 5/28/13, effective
					 7/1/13.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › OPIOIDS FOR NONCANCER PAIN › Section 296-20-03060 - Episodic care for pain

Current through Register Vol. 24-14, July 15, 2024
The department or self-insurer may pay for one pain-related
				  emergency or urgent care visit related to the accepted condition for a worker
				  already receiving opioid therapy, but payment for additional emergency or
				  urgent care visits may be denied. Urgent care visit includes any unscheduled
				  visit to other than the usual place of care for pain management.
Workers receiving opioid therapy should be managed by a
				  single prescribing provider.
Statutory Authority:
					 RCW
					 51.04.020 and
					 51.04.030. 13-12-024, §
					 296-20-03060, filed 5/28/13, effective
					 7/1/13.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › OPIOIDS FOR NONCANCER PAIN › Section 296-20-03065 - Managing surgical pain in workers on opioid therapy

Current through Register Vol. 24-14, July 15, 2024
The provider should taper the worker's total opioids to the
				  preoperative dose or lower by six weeks after surgery. Upon request, and
				  depending on the complexity of the surgery, the department or self-insurer may
				  authorize an additional six weeks for the provider to taper opioids to the
				  preoperative or lower dose.
Statutory Authority:
					 RCW
					 51.04.020 and
					 51.04.030. 13-12-024, §
					 296-20-03065, filed 5/28/13, effective
					 7/1/13.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › OPIOIDS FOR NONCANCER PAIN › Section 296-20-03070 - When opioid prescribing is not proper and necessary care

Current through Register Vol. 24-14, July 15, 2024
Continuing to prescribe opioids in the absence of clinically
				  meaningful improvement in function or after the development of a severe adverse
				  outcome, or prescribing opioids in escalating doses to the point of the worker
				  developing opioid use disorder is not considered proper and necessary care in
				  the Washington state workers' compensation system (see WAC
				  296-20-01002 for the definition
				  of proper and necessary care). Further coverage of opioids under these
				  circumstances is not payable.
Statutory Authority:
					 RCW
					 51.04.020 and
					 51.04.030. 13-12-024, §
					 296-20-03070, filed 5/28/13, effective
					 7/1/13.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › OPIOIDS FOR NONCANCER PAIN › Section 296-20-03075 - When to discontinue opioids

Current through Register Vol. 24-14, July 15, 2024
The prescriber must discontinue opioids under the following
				  circumstances:
. The worker requests opioid discontinuation; or
. The attending provider, because of concern for potential
				  adverse outcomes, requests opioid discontinuation; or
. The worker is maintained on opioids for at least three
				  months and there is no sustained clinically meaningful improvement in function,
				  as measured by validated instruments; or
. The worker's risk from continued treatment outweighs the
				  benefit; or
. The worker has experienced an opioid overdose event related
				  to aberrant behavior or substance use disorder (except nicotine) or a
				  prescribing pattern that is not in compliance with DOH's pain management rules,
				  L&I's rules, the agency medical directors' group's guideline or L&I's
				  guideline for prescribing opioids to treat pain in injured workers or the
				  worker has experienced any other severe adverse outcome; or
. There is a pattern of recurrent (more than one) aberrant
				  behaviors (including, but not limited to, inconsistent urine drug test result,
				  lost prescriptions, multiple requests for early refills, multiple prescribers,
				  unauthorized dose escalation, apparent intoxication); or
. Use of opioids is not in compliance with DOH's pain
				  management rules, L&I's rules, the agency medical directors' group's
				  guideline or L&I's guideline for prescribing opioids to treat pain in
				  injured workers.
Under these circumstances, the department or self-insurer may
				  pay for an opioid wean or detoxification to facilitate discontinuation of
				  opioids (see WAC
				  296-20-03080, Weaning or
				  detoxification). However, continued chronic opioid therapy is not
				  payable.
Statutory Authority:
					 RCW
					 51.04.020 and
					 51.04.030. 13-12-024, §
					 296-20-03075, filed 5/28/13, effective
					 7/1/13.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › OPIOIDS FOR NONCANCER PAIN › Section 296-20-03080 - Weaning or detoxification

Current through Register Vol. 24-14, July 15, 2024
The department or self-insurer may pay for adjuvant treatment
				  to aid with the weaning (see WAC
				  296-20-03030 for the definition
				  of step 1 and 2 taper) or detoxification process, except for ultra-rapid
				  detoxification (e.g., detoxification within three days using antagonist drugs
				  with or without sedation). The department or self-insurer is not responsible
				  for any adverse outcomes resulting from continued opioid use after completion
				  of a detoxification program.
Statutory Authority:
					 RCW
					 51.04.020 and
					 51.04.030. 13-12-024, §
					 296-20-03080, filed 5/28/13, effective
					 7/1/13.