Medical necessity

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