Medical services

1. Medical services. a. Medical services that are not medically necessary are not reimbursable. b. Frequency and extent of treatment may not be more than the nature of the injury or process of recovery requires, and must be provided in accordance with utilization and treatment standards as prescribed by the organization or the managed care vendor. The organization may require evidence of the efficacy of treatment. 2. Medical services may be reimbursed only when provided according to a written treatment plan. A copy of the treatment plan, signed by the allied health care professional, must be provided to the organization within fourteen days of beginning the treatment or within fourteen days of learning that the treatment is claimed to be work-related, whichever occurs later. However, a treatment plan is not required for a short course of treatment consisting of one or two visits. 3. For purposes of this section, a treatment plan must include: a. Objectives, including the degree of restoration anticipated. b. Measurable goals. c. Modalities and specific therapies to be used. d. Frequency and duration of treatments to be provided. e. Condition of the claimant which may require periodic modification of the plan of care based on: (1) Improvements in the claimant's status. (2) Failure of the claimant to improve as expected. (3) Intervention of care rendered, including education of the claimant, when appropriate. (4) Specific operative reports, test results, and consultation reports. 4. The cost of preparing a written treatment plan and supplying progress notes under this section is included in the fee for the medical service. 5. The treatment plan requirements of this section may be modified or waived by the organization. 6. X-ray images must be of diagnostic quality. Billings for x-rays are not reimbursable without a report of the findings. Upon request of either the organization or the managed care vendor, original x-ray images must be forwarded to the organization or the managed care vendor. A reasonable charge may be made for the costs of delivery of images. 7. A generic brand of therapeutic equivalence must be dispensed, provided the generic medication costs less. If the injured employee does not accept the generic equivalent at a lower price, the injured employee is responsible for the cost difference between the generic and brand name prescription medication. A branded equivalent of a generically available medication requires prior approval by the organization and will be covered only when objective medical evidence exists that the injured employee developed an adverse response to the generic medication.