Section 296-20-03001. Treatment requiring authorization.

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.

(8) Home nursing, attendant services or convalescent center care must be authorized per provisions outlined in WAC 296-20-091 or 296-23-246.

(9) Provision of prosthetics, orthotics, surgical appliances, special equipment for home or transportation vehicle; custom made shoes for ankle/foot injuries resulting in permanent deformity or malfunction of a foot; masking devices; hearing aids; etc., must be authorized in advance as per WAC 296-20-1101 and 296-20-1102.

(10) Biofeedback program; structured intensive multidisciplinary pain programs (SIMPs); pain clinic; weight loss program; psychotherapy; rehabilitation programs; and other programs designed to treat special problems must be authorized in advance. Refer to the department's medical aid rules and fee schedules for details.

(11) Prescription or injection of vitamins for specific therapeutic treatment of the industrial condition(s) when the attending doctor can demonstrate that published clinical studies indicate vitamin therapy is the treatment of choice for the condition. Authorization for this treatment will require presentation of facts to and review by department medical consultant.

(12) The long term prescription of medication under the specific conditions and circumstances in (a) and (b) of this subsection are considered corrective therapy rather than palliative treatment and approval in advance must be obtained.

(a) Nonsteroidal anti-inflammatory agents for the treatment of degenerative joint conditions aggravated by occupational injury.

(b) Anticonvulsive agents for the treatment of seizure disorders caused by trauma.

(13) The department may designate those diagnostic and surgical procedures which can be performed in other than a hospital inpatient setting. Where a worker has a medical condition which necessitates a hospital admission, prior approval of the department or self-insurer must be obtained.

[Statutory Authority: RCW 51.04.020 and 51.04.030. WSR 15-17-104, § 296-20-03001, filed 8/18/15, effective 10/1/15. Statutory Authority: RCW 70.14.110, 51.04.020, and 51.04.030. WSR 12-12-059, § 296-20-03001, filed 6/5/12, effective 7/6/12. Statutory Authority: RCW 51.04.020, 51.04.030, and Title 51 RCW. WSR 08-24-047, § 296-20-03001, filed 11/25/08, effective 12/26/08. Statutory Authority: RCW 51.04.020, 51.04.030, 51.32.060, 51.32.072, and 7.68.070. WSR 01-18-041, § 296-20-03001, filed 8/29/01, effective 10/1/01. Statutory Authority: RCW 51.04.020, 51.04.030 and 1993 c 159. WSR 93-16-072, § 296-20-03001, filed 8/1/93, effective 9/1/93. Statutory Authority: RCW 51.04.020(4) and 51.04.030. WSR 90-04-057, § 296-20-03001, filed 2/2/90, effective 3/5/90; WSR 86-20-074 (Order 86-36), § 296-20-03001, filed 10/1/86, effective 11/1/86; WSR 86-06-032 (Order 86-19), § 296-20-03001, filed 2/28/86, effective 4/1/86; WSR 83-16-066 (Order 83-23), § 296-20-03001, filed 8/2/83. Statutory Authority: RCW 51.04.020(4), 51.04.030, and 51.16.120(3). WSR 81-24-041 (Order 81-28), § 296-20-03001, filed 11/30/81, effective 1/1/82; WSR 81-01-100 (Order 80-29), § 296-20-03001, filed 12/23/80, effective 3/1/81. Statutory Authority: RCW 51.04.030 and 51.16.035. WSR 79-12-086 (Order 79-18), § 296-20-03001, filed 11/30/79, effective 1/1/80; Order 76-34, § 296-20-03001, filed 11/24/76, effective 1/1/77.]

RCW 51.04.020 and 51.04.030. WSR 15-17-104, § 296-20-03001, filed 8/18/15, effective 10/1/15. Statutory Authority: RCW 70.14.110, 51.04.020, and 51.04.030. WSR 12-12-059, § 296-20-03001, filed 6/5/12, effective 7/6/12. Statutory Authority: RCW 51.04.020, 51.04.030, and Title 51 RCW. WSR 08-24-047, § 296-20-03001, filed 11/25/08, effective 12/26/08. Statutory Authority: RCW 51.04.020, 51.04.030, 51.32.060, 51.32.072, and 7.68.070. WSR 01-18-041, § 296-20-03001, filed 8/29/01, effective 10/1/01. Statutory Authority: RCW 51.04.020, 51.04.030 and 1993 c 159. WSR 93-16-072, § 296-20-03001, filed 8/1/93, effective 9/1/93. Statutory Authority: RCW 51.04.020(4) and 51.04.030. WSR 90-04-057, § 296-20-03001, filed 2/2/90, effective 3/5/90; WSR 86-20-074 (Order 86-36), § 296-20-03001, filed 10/1/86, effective 11/1/86; WSR 86-06-032 (Order 86-19), § 296-20-03001, filed 2/28/86, effective 4/1/86; WSR 83-16-066 (Order 83-23), § 296-20-03001, filed 8/2/83. Statutory Authority: RCW 51.04.020(4), 51.04.030, and 51.16.120(3). WSR 81-24-041 (Order 81-28), § 296-20-03001, filed 11/30/81, effective 1/1/82; WSR 81-01-100 (Order 80-29), § 296-20-03001, filed 12/23/80, effective 3/1/81. Statutory Authority: RCW 51.04.030 and 51.16.035. WSR 79-12-086 (Order 79-18), § 296-20-03001, filed 11/30/79, effective 1/1/80; Order 76-34, § 296-20-03001, filed 11/24/76, effective 1/1/77.

Rules

296-21,296-23A,296-20-091,296-23-246,296-20-1101,296-20-1102,