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 85-20 - Medical Management Of Claims, Guidelines For Impairment Evaluations, Evidence, And Ratings, And Ranges Of Permanent Partial Disability Awards › Section 85-20-34 - Treatment Guidelines: Functional Capacity Evaluations: Work Conditioning and Work Hardening Rehabilitation Programs. (Effective Date: February 1, 2005)

Current through Register Vol. XLI, No. 28, July 12, 2024
34.1.
				Functional capacity evaluations. Functional capacity evaluations measure or
				quantify the physical abilities of an injured worker identified as essential in
				performing suitable, gainful employment and/or objectively define an injured
				worker's functional abilities or limitations in the context of safe and
				productive work. A functional capacity evaluation does not reflect what an
				individual should be able to do; but rather, what an individual can do or is
				willing to do at a given time. The functional capacity evaluator must be
				qualified by reason of training and experience and must employ valid, generally
				accepted scientific methodology in determining the injured worker's
				ability.
34.2. Functional capacity
				evaluation providers. Functional capacity evaluations shall be performed by an
				approved licensed occupational therapist or physical therapist, with the
				limited exception as described within this subsection. Medical doctors, doctors
				of osteopathy and chiropractors shall not perform functional capacity
				evaluations, unless they meet the exception described in the section.
34.3. Functional capacity evaluation provider
				qualifications.
a. The approved functional
				capacity evaluation provider shall:
1. Submit
				specific documented post professional education and training in occupational
				rehabilitation and/or training for the model of functional capacity evaluation
				they are providing, and
2. Have a
				minimum of one year of supervised patient care experience in an outpatient
				industrial, orthopedic or sports medicine setting. A minimum of 25% of the
				provider in training's work experience must be spent working with injured
				workers.
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 85-20-35 - Treatment Guidelines: Cervical Musculoligamentous Injury (Sprain/Strain)

Current through Register Vol. XLI, No. 28, July 12, 2024
35.1. Symptoms are
				believed to be related to a partial stretching or tearing of the soft tissues
				(muscles, fascia, ligaments, facet joint capsule, etc.). Neck pain may be
				accompanied by vague upper extremity complaints. The recovery period is of
				variable duration, but generally is less than three or four weeks.
35.2. The appropriate diagnostic criteria
				consists of the following:
a. Pertinent
				historical and physical findings documenting the mechanism and degree of force
				and the time sequence before the onset of symptoms is important. The onset of
				neck pain and paraspinal muscle spasm begins either suddenly after the injury
				occurs or develops gradually over the next 24 hours. This pain is usually
				aggravated by motion of the neck and frequently is relieved by rest. It can be
				accompanied by paresthesia or a sense of weakness in the upper extremities
				related to the muscle spasm in the neck. Physical findings include tenderness
				to palpation, spasm of the paravertebral muscles and aggravation of the pain
				with motion.
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 85-20-37 - Treatment Guidelines: Low Back Musculoligamentous Injury (Sprain/Strain)

Current through Register Vol. XLI, No. 28, July 12, 2024
37.1. Strains and
				sprains are a common cause of acute low back pain encountered in the general
				population. These injuries often are the result of the mechanical stresses and
				functional demands placed on the low back area by everyday activities. Symptoms
				are believed to be related to a partial stretching or tearing of the soft
				tissues (muscles, fascia, ligaments, facet joint capsule, etc.) The conditions,
				for the vast majority of injured workers, are of short duration and complete
				recovery is the general rule. Most injured workers with a musculoligamentous
				injury to the low back recover rapidly, with 50% to 60% of injured workers
				recovering within one week.
37.2.
				The appropriate diagnostic criteria consist of:
Onset of low back pain and paraspinal muscle spasm begins
				  either suddenly after the injury occurs or develops gradually over the next 24
				  hours. The pain is usually relieved by rest and aggravated by motion of the
				  back. The pain usually does not radiate below the knee, and the strain is not
				  accompanied by paresthesias or muscle weakness in the legs. Physical findings
				  include low back tenderness to palpation, loss of normal lumbar lordosis, and
				  spasm of the paravertebral muscles. Straight leg raising and other tests that
				  cause spinal motion may increase low back pain. The injured worker may stand
				  with a list to the side or in a flexed position. The neurological examination
				  and nerve root stretch tests usually are negative.
37.3. Appropriate and inappropriate
				diagnostic tests and examinations are as follows:
a. Although the diagnosis of a
				musculoligamentous injury is not based on radiographic criteria, plain x-rays
				may be indicated based on mechanism of injury (actual trauma, hyperextension,
				compression), a high index of clinical signs of pathology, or treatment plan
				for manipulative therapy. Pain, which persists (no improvement) longer than 2-4
				weeks or worsens may also be criteria for x-rays.
b. Inappropriate diagnostic tests and
				examinations during the acute phase of the first four weeks:
1. CT scan;
2. MRI;
3. Bone scans;
4. Myelography;
5. EMG;
6. *Thermogram;
7. *Evoked Potentials;
8. *Myeloscopy; and
9. *Spinoscopy;
*Never appropriate
c. Failure to improve in four weeks warrants
				an appropriate second opinion.
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 85-20-39 - Treatment Guidelines: Lumbar Fusion

Current through Register Vol. XLI, No. 28, July 12, 2024
39.1. Indications of compensable lumbar
				fusion:
a. Injuries to bone or soft tissue
				that cause instability;
b. For a
				second or third time disc surgery, the injured worker must have a second
				medical opinion and prior approval from 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 85-20-40 - Treatment Guidelines: Shoulder Injury Guidelines

Current through Register Vol. XLI, No. 28, July 12, 2024
40.1. The term "shoulder complex" refers to
				the humerus, clavicle, scapula and the surrounding supporting connective tissue
				and emphasizes their interdependent relationship. Articulations of the
				"shoulder complex" are the sternoclavicular, acromioclavicular,
				scapulothoracic, glenohumeral, and subacromial arch.
Fractures, separations, or subluxations/dislocations of
				  components within the "shoulder complex" result from trauma to the shoulder
				  girdle or upper extremity. Soft tissue strains or sprains may result from
				  either trauma or longstanding accumulative microtrauma. The rotator cuff is
				  particularly vulnerable to overuse pathology.
Treatment of "shoulder complex" injuries is directed to
				  restoring balanced motion in the entire complex. Because of the importance of
				  the soft tissues, physical therapy is very important and can be lengthy. On the
				  other hand, because the shoulder complex is so adaptable, most individuals can
				  find alternative patterns of function in their work, home, or recreational
				  needs while they are undergoing physical rehabilitation.
40.2. The appropriate diagnostic criteria are
				as follows:
a. History and physical.
1. Mechanism of injury - single episode or
				repetitive microtrauma.
2. Pain
				pattern - pain at rest, pain related to work, activities of daily living, or
				recreational activities, night pain; painful arc of motion; position of
				comfort; relative position of the pain; relative position of the neck; referred
				pattern (pain below the elbow suggests a radicular component).
3. Range-of-motion - active glenohumeral and
				scapulothoracic balance; passive forward flexion, external rotation, internal
				rotation, and abduction compared to the opposite side.
4. Palpation - point or zone of maximum
				tenderness.
5. Neurological -
				motor, sensory, muscle stretch reflexes for C5, C6, C7, C8 and T1
				roots.
6. Special tests -
				apprehension; drop arm; impingement; Yergason; posterior apprehension; sulcus
				sign; clunk; AC spring; Adson; Awinged scapular; lateral scapular
				slide.
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 85-20-41 - Treatment Guidelines: Carpal Tunnel Syndrome

Current through Register Vol. XLI, No. 28, July 12, 2024
41.1. The purpose of the Carpal Tunnel
				Syndrome ("CTS") Rule is to provide the treating physician with treatment
				guidance and treatment parameters so that the treating team can:
a. Determine if the illness is work-related;
				that is, determine causality.
b.
				Properly diagnose the illness through a careful history, physical examination
				and appropriate diagnostic tests and examinations.
c. Initiate timely and proper treatment;
				and
d. Keep the injured worker in
				the workplace, through modified or restricted duty if necessary, as much as
				possible during the treatment plan.
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 85-20-42 - Treatment Guidelines: Injuries to the Knee

Current through Register Vol. XLI, No. 28, July 12, 2024
42.1. The vast majority of knee injuries
				result from direct trauma to the joint or are caused by torsional or angulatory
				forces. These injuries vary in severity from simple ligamentous strains to
				complex injuries involving ligamentous disruption with meniscal damage and
				associated fracture. This guideline is designed to guide the practitioner in
				the appropriate management of these injuries and to establish a logical
				sequence for the diagnostic evaluation and treatment of the more complex
				injuries.In general, knee injuries should be referred for orthopedic
				consultation and/or treatment under the following circumstances:
a. Failure of a presumed knee sprain to show
				progressive resolution and respond to appropriate conservative treatment in a
				period of three (3) weeks;
b.
				Radiographic evidence of an associated fracture;
c. The initial presence of a tense
				hemarthrosis or the development of a recurrent hemarthrosis;
d. An acutely locked or an acutely dislocated
				knee;
e. Clinical evidence of gross
				ligamentous instability; and f. A presumed diagnosis of a meniscal
				injury.
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 85-20-43 - Treatment Guidelines: Knee Sprains

Current through Register Vol. XLI, No. 28, July 12, 2024
43.1. These are common injuries resulting
				from the application of a torsional or angulatory force to the knee and are
				characterized by pain, mild swelling, localized tenderness, increased
				discomfort or weight bearing, negative x-rays, and no clinical evidence of
				instability.
a. The appropriate diagnostic
				tests.
1. Plain x-rays.
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 85-20-44 - Treatment Guidelines: Meniscal Injuries

Current through Register Vol. XLI, No. 28, July 12, 2024
44.1. The mechanism of injury is similar to
				that for knee sprains but symptoms of pain and swelling fail to resolve in the
				anticipated period of time and the symptoms frequently include a sensation of
				"catching or giving away" of the joint and a history of locking of the joint
				may be elicited.
Clinical findings may include joint space tenderness, a mild
				  effusion and restricted range-of-motion and positive McMurray's sign.
44.2. The appropriate diagnostic
				tests are as follows:
a. Plain
				x-rays;
b.
				Arthrocentesis;
c. MRI;
d. Arthrogram; and
e. Diagnostic arthroscopy.
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 85-20-45 - Treatment Guidelines: Foot and Ankle Injuries

Current through Register Vol. XLI, No. 28, July 12, 2024
45.1. Injuries to the foot and ankle usually
				relate to a specific traumatic event and have a predictable clinical course
				depending on the severity index of the initial injury. For simplicity, injuries
				will be discussed relative to the anatomic region of the foot and ankle (ankle,
				hind foot, midfoot, forefoot or phalanges).
45.2. The appropriate diagnostic criteria is
				as follows:
a. Pertinent historical and
				physical findings:
1. Onset of pain and/or
				swelling is related to a single event, either a twisting injury, fall or direct
				blunt trauma. The degree of the injury can be judged quickly by determining
				which one can bear weight and the degree of initial swelling. The more severe
				injuries will have greater swelling, inability to bear weight, and may have
				obvious deformity.
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 85-20-46 - Treatment Guidelines: Physical Medicine

Current through Register Vol. XLI, No. 28, July 12, 2024
46.1. Principles for use of physical
				medicine:
a. Physical medicine should be
				initiated as early as the day of injury; indications for and focus of (early)
				intervention include:
1. Acute management of
				pain and spasms;
2. Use of passive
				modalities as adjunct to active treatment;
3. Manual therapy for restoring joint
				function;
4. Instruction in range
				of motion and stretching exercises;
5. Assessment of return to work readiness and
				identifying necessary work modifications;
6. Injured worker education in healing
				process, body mechanics, proper resting positions, and home treatment program;
				and
7. Time frames may range from
				one visit to daily visits in accordance with applicable treatment
				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 85-20-47 - Treatment Guidelines, Protocols and Procedures for Performing Audiological Examinations and Evaluations in Workers' Compensation Claims for Noise-Induced Hearing Loss

Current through Register Vol. XLI, No. 28, July 12, 2024
47.1. Only
				audiometric test results obtained by an audiologist having a certificate of
				clinical competence in audiology (CCC-A) or a West Virginia audiology licensure
				are acceptable for purposes of awarding compensation. An audiogram performed at
				the request of any physician may be utilized by the injured worker for the
				purpose of completing the workers' compensation application form. However, only
				physicians who are qualified otologists or otolaryngologists may interpret the
				results of audiograms in assessing the degree of the injured worker's
				noise-induced hearing loss impairment for the purpose of determining the
				percentages of the injured worker's whole person impairment, if any.
47.2. A physician examining and evaluating an
				injured worker in a noise-induced hearing loss claim must consider the injured
				worker's medical and occupational history, as well as available audiograms, in
				determining the etiology of the hearing loss. It is not necessary to use a
				uniform brand and model of audiometer.
For Commission, Insurance Commissioner, private carrier or
				  self-insured employer, whichever is applicable, standards, the audiologist
				  shall adopt the ANSI Guidelines and perform an annual exhaustive calibration.
				  The audiologist should also perform a daily listening check.
47.3. Establishing a definitive margin of
				error: Two audiograms are said to be in acceptable test-retest variability when
				the total of four frequencies (500, 1000, 2000, 3000 Hz) is 15 decibels or less
				and the audiometric curves are similar. Because the two audiograms are
				technically identical and one cannot be chosen over the other, the calculation
				of whole person impairment will be based on the audiogram that yields the
				highest degree of impairment for the injured worker.
a. If two audiograms are both rated "good",
				and differ by more than the established margin of error, the Commission,
				Insurance Commissioner, private carrier or self-insured employer, whichever is
				applicable, shall arrange for a third independent evaluation by an otologist or
				otolaryngologist.
b. The two
				audiograms that are within an acceptable test/retest variability should be
				used.
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 85-20-48 - Reserved

Current through Register Vol. XLI, No. 28, July 12, 2024
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 85-20-49 - Treatment Guidelines: Multi- Disciplinary Pain Management

Current through Register Vol. XLI, No. 28, July 12, 2024
49.1. It is now
				well accepted that chronic pain treatment is a complex problem that involves
				physical, emotional and behavioral components. Chronic pain and treatment
				therefore, including multidisciplinary interventions, is only compensable if
				specifically diagnosed as caused by an injury received in the course of and
				resulting from employment.
49.2.
				Multidisciplinary treatment for chronic pain and related disability has been
				more rigorously examined than most other treatments used with chronic pain.
				There is strong evidence for the importance of the behavioral/psychological
				component of treatment in making meaningful changes in pain intensity,
				functional status and emotional distress.
49.3. The best predictors of disability and
				response to multidisciplinary treatment may not be a function of physical or
				medical variables; instead, psychological variables may be the best predictors
				in certain cases. Additionally, assessment of psychosocial "risk factors" for
				chronic disability done shortly after injury can lead to more effective
				management by identifying which patients are likely to benefit from
				multidisciplinary treatment.
49.4.
				Chronic Pain Syndrome: Chronic Pain Syndrome patients are defined by the
				following criteria:
a) Reports of persistent
				(i.e., at least four months duration) pain, which may be consistent with or
				significantly out of proportion to physical findings; b). Demonstrates or has
				demonstrated a progressive deterioration in ability to function at home,
				socially and at work; c) Shows or has shown a progressive increase in health
				care utilization (such as repeated physical evaluations, diagnostic tests,
				requests for pain medications and/or invasive medical procedures); d)
				Demonstrates mood disturbance; and e) May exhibit clinically significant anger,
				frustration and/or hostility.
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 85-20-51 - Treatment Guidelines: Complex Regional Pain Syndrome

Current through Register Vol. XLI, No. 28, July 12, 2024
51.1. Background: Complex regional pain
				syndrome (CRPS) is a descriptive term encompassing a variety of painful
				conditions following injury, which appear regionally and have a distal
				predominance of abnormal physical examination findings. This painful condition
				typically follows a traumatic injury or noxious event to an extremity, with a
				disproportionate response respective to the original insult. Medical conditions
				including stroke and myocardial infarction may also be precipitating factors.
				The pain pattern is not limited to the distribution of a single peripheral
				nerve, and physical findings include edema, alterations in skin blood flow,
				abnormal sudomotor activity in the region of pain, allodynia or hyperalgesia.
				Treatment for CRPS is only compensable if directly caused by an injury received
				in the course of and resulting from employment.
51.2. CRPS Type I (Reflex Sympathetic
				Dystrophy).
a. Type 1 CRPS is a syndrome that
				may develop after an initiating noxious event.
b. Spontaneous pain or allodynia/
				hyperalgesia occurs, but is not limited to the territory of a single peripheral
				nerve and is disproportionate to the inciting event.
c. There is or has been evidence of edema,
				skin blood flow abnormality, or abnormal sudomotor activity in the region of
				the pain since the inciting event.
d. The diagnosis is excluded by the existence
				of conditions that would otherwise account for the degree of pain and
				dysfunction.
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 85-20-53 - Long-Term Opioid Therapy Guideline

Current through Register Vol. XLI, No. 28, July 12, 2024
53.1. These guidelines are used by the
				provider in the management of chronic nonmalignant pain. Chronic nonmalignant
				pain is defined as pain persisting beyond the expected normal healing time for
				an injury, for which traditional medical approaches have been unsuccessful.
				These guidelines do not apply to claimants whose pain is the result of a
				malignant process (cancer), or when the pain therapy is aimed at relieving
				intractable pain and suffering in the terminally ill when other measures fail,
				assuming a compensable diagnosis.
53.2. Successful management of intractable
				chronic non-malignant pain (hereinafter referred to as "chronic pain") usually
				does not require the use of opioid medications. There are other effective and
				non-pharmacologic treatment interventions available. Some carefully selected
				claimants with chronic pain may benefit from opioid maintenance analgesia
				(OMA). These claimants function better, are sometimes able to resume working,
				maintain improved pain control with acceptable side effects, and continue to
				use their medications in a responsible manner.
53.3. In some claimants, long-term OMA fails.
				Pain control is marginal, function does not improve, side effects prohibit
				ongoing therapy, or the claimant's ability to use the medication properly is
				poor or erratic. The key to success in the management of OMA is careful
				selection of candidates and monitoring.
53.4. Candidates for long -- term OMA should:
a. Have an established diagnosis that is
				consistent with chronic pain.
b.
				Have not responded to non-opioid treatment.
c. Not be pregnant. Claimants likely to
				become pregnant during the course of treatment must be advised of the risks to
				the fetus should pregnancy occur.
d. Not be using illegal drugs or abusing
				alcohol.
e. Be reliable claimants
				who are known to the physician and are expected to be compliant with the
				treatment protocol.
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 85-20-54 - Drugs with Specific Limitations

Current through Register Vol. XLI, No. 28, July 12, 2024
54.1. Injectables. Prescriptions for
				injectable opioids or other analgesics, sedatives, antihistamines,
				tranquilizers, psychotropics, vitamins, minerals, food supplements, and
				hormones are not covered.
54.2.
				Exceptions: The Commission, Insurance Commissioner, private carrier or
				self-insured employer, whichever is applicable, covers injectable medications
				under the following circumstances.
a.
				Indicated injectable drugs for the following:
1. Inpatients; or
2. During emergency treatment of a
				life-threatening condition/injury; or
3. During outpatient treatment of severe soft
				tissue injuries, burns or fractures when needed for dressing or cast changes;
				or
4. During the perioperative
				period and the postoperative period, not to exceed forty-eight hours from the
				time of discharge.
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 85-20-55 - Drugs and Medications: Actions

Current through Register Vol. XLI, No. 28, July 12, 2024
55.1. The Commission, Insurance Commissioner,
				private carrier or self-insured employer, whichever is applicable, may take any
				or all of the following steps when concerned about the amount or
				appropriateness of drugs the patient is receiving:
a. Notify the attending physician of concerns
				regarding the medications such as drug interactions, adverse reactions,
				prescriptions by other providers;
b. Require that the attending physician send
				a treatment plan addressing the drug concerns;
c. Request a consultation from an appropriate
				specialist;
d. Request that the
				attending physician consider reducing the prescription, and provide information
				on chemical dependency programs;
e.
				Limit payment for drugs on a claim to one prescribing doctor.
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 85-20-56 - Physician's Records of Medication

Current through Register Vol. XLI, No. 28, July 12, 2024
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. Failure to maintain
				  these records may be considered abuse under W. Va. Code §
									23-4-3c.
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 85-20-57 - Payment for oral opioid treatment for chronic, noncancer pain

Current through Register Vol. XLI, No. 28, July 12, 2024
Chronic, noncancer pain may develop after an acute injury
				  episode. It is defined as pain that typically persists beyond two to four
				  months following the injury. The Commission, Insurance Commissioner, private
				  carrier or self-insured employer, whichever is applicable, in its sole
				  discretion, may pay for oral opioids for the treatment of chronic, noncancer
				  pain caused by an accepted condition when that treatment is reasonably
				  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 85-20-58 - Required authorization for treatment of chronic, noncancer pain with opioids

Current through Register Vol. XLI, No. 28, July 12, 2024
58.1. No
				later than thirty days after the attending physician begins treating the worker
				with opioids for chronic, noncancer pain, the attending physician must submit a
				written report to the Commission, Insurance Commissioner, private carrier or
				self-insured employer, whichever is applicable, in order for the Commission,
				Insurance Commissioner, private carrier or self-insured employer, whichever is
				applicable, to pay for such treatment. The written report must include the
				following:
a. A treatment plan with
				time-limited goals, including a time schedule to wean the injured worker from
				opiod use;
b. A consideration of
				relevant prior medical history;
c.
				A summary of conservative care rendered to the worker that focused on
				reactivation and return to work;
d.
				A statement on why prior or alternative conservative measures may have failed
				or are not appropriate as sole treatment;
e. A summary of any consultations that have
				been obtained, particularly those that have addressed factors that may be
				barriers to recovery;
f. A
				statement that the attending physician has conducted appropriate screening for
				factors that may significantly increase the risk of abuse or adverse outcomes
				(e.g., a history of alcohol or other substance abuse); and g. An opioid
				treatment agreement that has been signed by the worker and the attending
				physician. This agreement must be renewed every six months. The treatment
				agreement must outline the risks and benefits of opioid use, the conditions
				under which opioids will be prescribed, the physician's need to document
				overall improvement in pain and function, and the worker's
				responsibilities.
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 85-20-59 - Required documentation to be submitted for continued coverage of opioids to treat chronic, noncancer pain

Current through Register Vol. XLI, No. 28, July 12, 2024
59.1. In addition to the general
				documentation required by the Commission, Insurance Commissioner, private
				carrier or self-insured employer, whichever is applicable, the attending
				physician must submit the following information at least every sixty days when
				treating with opioids:
a. Documentation of
				drug screenings, consultations, and all other treatment trials;
b. Documentation of outcomes and responses,
				including pain intensity and functional levels; and c. Any modifications to the
				treatment plan.
The physician must document the patient's improvement in
				  pain intensity and functional levels.
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 85-20-60 - Duration of payment for opioids to treat chronic, noncancer pain

Current through Register Vol. XLI, No. 28, July 12, 2024
60.1. The
				Commission, Insurance Commissioner, private carrier or self-insured employer,
				whichever is applicable, will continue to pay for treatment with opioids if
				directly related to a compensable condition so long as the physician documents
				in addition to the information required in Section 58 of this Rule:
a. Substantial reduction of the patient's
				pain intensity; and
b. Continuing
				substantial improvement in the patient's function. Once the worker's condition
				has reached maximum medical improvement, further treatment with opioids is not
				payable. Opioid treatment for chronic, noncancer pain past the first three
				months of such treatment without documentation of substantial and progressive
				continuing improvement is presumed to be not proper and
				necessary.
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 85-20-61 - Denial of payment of opioid medications used to treat chronic, noncancer pain

Current through Register Vol. XLI, No. 28, July 12, 2024
61.1. Payment
				for opioid medications may be denied in any of the following circumstances:
" Absent or inadequate documentation;
" Noncompliance with the treatment plan;
" Pain and functional status have not substantially improved
				  after three months of opioid treatment; or
" Evidence of misuse or abuse of the opioid medication or
				  other drugs, or noncompliance with the attending physician's request for a drug
				  screen.
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 85-20-62 - Payment for nonopioid medications for the treatment of chronic, noncancer pain; Chelation therapy

Current through Register Vol. XLI, No. 28, July 12, 2024
62.1. The
				Commission, Insurance Commissioner, private carrier or self-insured employer,
				whichever is applicable, may pay for nonopioid medication for the treatment of
				chronic, noncancer pain when it is proper and necessary and directly related to
				a compensable injury. For example, some drugs such as anti-convulsants,
				anti-depressants, and others have been demonstrated to be useful in the
				treatment of chronic pain and may be approved when proper and
				necessary.
62.2. All chelation
				therapy (oral and IV) requires prior authorization and consultation with a
				Board Certified Medical Toxicologist, an occupational medicine specialist, or
				general internist familiar with principals of toxicology, prior to initiation
				of the therapy. In the rare incident, in which acute encephalopathy occurs as
				the result of heavy metal toxicity, a consultation with the Poison Control
				Center will serve as confirmation of the need for such chelation therapy. The
				Commission, Insurance Commissioner, private carrier or self-insured employer,
				whichever is applicable, will not reimburse for IV chelation therapy performed
				in office.
VI.
EXPECTED PERIOD OF TIME
				TO REACH MAXIMUM MEDICAL IMPROVEMENT
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 85-20-63 - Expected period of time to reach maximum medical improvement

Current through Register Vol. XLI, No. 28, July 12, 2024
Pursuant to W. Va. Code §
									23-4-3b(b),
				  the Commission or Insurance Commissioner, whichever is applicable, hereby
				  incorporates by reference the Medical Disability Advisor, Workplace Guidelines
				  for Disability Duration, Presley Reed, MD (4th
				  Edition) ("Presley Reed Guide") for purposes of establishing the expected
				  period of time to reach maximum medical improvement and for continued treatment
				  for various injuries and diseases. The requirements, standards, parameters and
				  limitations of the Presley Reed Guide shall have the same force and effect as
				  this Rule. All requirements, standards, parameters and limitations of the
				  Presley Reed Guide are hereby deemed medically reasonable and any requirements,
				  standards, parameters and limitations which exceed those set forth in the
				  Presley Reed Guide are hereby deemed 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 requirements, standards, parameters and limitations in excess of
				  those provided for in the Presley Reed Guide are medically reasonable.
Nothing in this rule shall prohibit employers, private
				  carriers or self-insured employers, whichever is applicable, from using other
				  guidelines for the purpose of establishing the expected period of time and
				  medical treatment protocols necessary to reach maximum medical improvement for
				  various injuries and diseases, as long as such guidelines are part of a managed
				  care plan otherwise approved by the Commission or Insurance commissioner,
				  whichever is applicable, pursuant to W. Va. Code §
									23-4-3(b)(2)(2003).
VII.
RANGE OF PARTIAL DISABILITY
				AWARDS FOR COMMON INJURIES AND DISEASES
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 85-20-65 - Adoption of Standards

Current through Register Vol. XLI, No. 28, July 12, 2024
65.1.
				Except as provided for in section 66 of this Rule, on and after the effective
				date of this rule all evaluations, examinations, reports, and opinions with
				regard to the degree of permanent whole body medical impairment which an
				injured worker has suffered shall be conducted and composed in accordance with
				the "Guides to the Evaluation of Permanent Impairment,"
				(4th ed. 1993), as published by the American Medical
				Association. If in any particular claim, the examiner is of the opinion that
				the Guides or the section 64 substitutes cannot be appropriately applied or
				that an impairment guide established by a recognized medical specialty group
				may be more appropriately applied, then the examiner's report must document and
				explain the basis for that opinion. Deviations from the requirements of the
				Guides or the section 6 substitutes shall not be the basis for excluding
				evidence from consideration. Rather, in any such instance such deviations shall
				be considered in determining the weight that will be given to that evidence. An
				example of an acceptable recognized medical specialty group's own guides is the
				"Orthopedic Surgeons Manual in Evaluating Permanent Physical
				Impairment."
65.2. These revised
				rules are not applicable to any permanent impairment rating examination
				performed prior to the effective date of these revised rules. Accordingly, the
				revised rules are not applicable to any reports or opinions based upon those
				examinations, in whole or in part, which are submitted either before or after
				the effective date of these revised rules.
65.3. These rules are applicable to
				examinations and opinions provided to the Commission, Insurance Commissioner,
				private carrier or self-insured employer, whichever is applicable, by an
				injured worker's treating physician pursuant to W. Va. Code §
									23-4-7a(c)(1).
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 85-20-66 - Evidentiary Requirements

Current through Register Vol. XLI, No. 28, July 12, 2024
66.1.
				The evidentiary weight to be given to a report will be determined by how well
				it demonstrates that the evaluation and examination that it memorializes were
				conducted in accordance with the applicable Guides and that the opinion with
				regard to the degree of permanent whole body medical impairment suffered by an
				injured worker was arrived at and composed in accordance with the requirements
				of the applicable Guides.
66.2. The
				report must state the factual findings of all tests, evaluations, and
				examinations that were conducted and must state the manner in which they were
				conducted so as to clearly indicate their performance in keeping with the
				requirements of the Guides. For any evaluation and examination of a compensable
				back injury, the back examination form previously adopted by the Workers'
				Compensation Commission must be completed and submitted with the narrative
				report. A copy of the current edition of the back examination form can be
				obtained from the Commission, Insurance Commissioner, private carrier or
				self-insured employer, whichever is applicable. A report and opinion submitted
				regarding the degree of permanent whole body medical impairment as a result of
				a back injury without a completed back examination form shall be
				disregarded.
66.3. The opinion
				stated in the report as to the degree of permanent whole body medical
				impairment must reflect the process of calculation as stated in the applicable
				Guides so as to demonstrate how the degree of permanent whole body medical
				impairment was arrived at and calculated.
66.4. To the extent that factors other than
				the compensable injury may be affecting the injured worker's whole body medical
				impairment, the opinion stated in the report must, to the extent medically
				possible, determine the contribution of those other impairments whether
				resulting from an occupational or a nonoccupational injury, disease, or any
				other cause.
66.5. In any claim for
				occupational pneumoconiosis benefits, for noise induced hearing loss, or for
				mental and emotional loss, the application of these evidentiary requirements of
				this section shall be based upon the guidelines referred to below in lieu of
				the Guides. All of the other requirements of this section shall be accordingly
				applied.
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 85-20-67 - Exceptions to the Guides

Current through Register Vol. XLI, No. 28, July 12, 2024
The following portions of the applicable Guides or their
				  successor provisions shall not be used in the determination of the degree of
				  permanent impairment that has been suffered by an injured worker for workers'
				  compensation benefits.
67.1. In claims
				for occupational pneumoconiosis benefits, the provisions of Chapter 5, "The
				Respiratory System," are exempted from this rule. The provisions of the statute
				related to occupational pneumoconiosis, rules adopted in accordance with the
				statute, and policies and procedures adopted by the occupational pneumoconiosis
				board adequately and separately control the determination of the degree of
				permanent impairment suffered by such an injured worker. The occupational
				pneumoconiosis board may, in any given case and in its discretion, utilize the
				Guides to the extent the board deems appropriate.
67.2. In claims for noise induced hearing
				loss, the provisions of section 9.1, Chapter 9, "Ear, Nose, Throat, and Related
				Structures," are exempted from this rule. The applicable exempt legislative
				rule has been promulgated for such claims.
67.3. In claims for mental and emotional
				loss, the provisions of chapter 14, "Mental and Behavioral Disorders," are
				exempted from this rule. This rule shall be utilized.
67.4. In those claims affected by the
				provisions of W. Va. Code §
									23-4-6(f),
				the degree of disability stated there shall be applied.
67.5. In those claims affected by the
				provisions of W. Va. Code §
									23-4-6(m),
				the conclusive presumption of total disability stated there shall be
				applied.