Current through Register Vol. 49, No. 13, September 23, 2024
Subpart 1.
General.
A. All treatment must
be medically necessary treatment, as defined in part
5221.6040, subpart
10. The health care provider
must evaluate the medical necessity of all treatment under item B on an ongoing
basis.
Parts
5221.6050 to
5221.6600 do not require or permit
any more frequent examinations than would normally be required for the
condition being treated, but do require ongoing evaluation of the patient that
is medically necessary, consistent with accepted medical practice.
B. The health care provider must
evaluate at each visit whether initial nonsurgical treatment for the low back,
cervical, thoracic, upper extremity, complex regional pain syndrome, reflex
sympathetic dystrophy, causalgia, and cognate conditions specified in parts
5221.6200,
5221.6205,
5221.6210,
5221.6300, and
5221.6305, is effective according
to subitems (1) to (3). No later than any applicable treatment response time in
parts
5221.6200 to
5221.6305, the health care
provider must evaluate whether the passive, active, injection, or medication
treatment modality is resulting in progressive improvement as specified in
subitems (1) to (3):
(1) the employee's
subjective complaints of pain or disability are progressively improving, as
evidenced by documentation in the medical record of decreased distribution,
frequency, or intensity of symptoms;
(2) the objective clinical findings are
progressively improving, as evidenced by documentation in the medical record of
resolution or objectively measured improvement in physical signs of injury;
and
(3) the employee's functional
status, especially vocational activities, is progressively improving, as
evidenced by documentation in the medical record, or successive reports of work
ability, of less restrictive limitations on activity.
Except as otherwise provided under parts
5221.6200, subpart
3, item B; 5221.6205, subpart
3, item B; 5221.6210, subpart
3, item B; and 5221.6300,
subpart
3, item B, if there is not
progressive improvement in at least two of subitems (1) to (3), the modality
must be discontinued or significantly modified, or the provider must reconsider
the diagnosis. The evaluation of the effectiveness of the treatment modality
can be delegated to an allied health professional directly providing the
treatment, but remains the ultimate responsibility of the treating health care
provider who ordered the treatment.
C. The health care provider must use the
least intensive setting appropriate and must assist the employee in becoming
independent in the employee's own care to the extent possible so that prolonged
or repeated use of health care providers and medical facilities is
minimized.
Subp. 2.
Documentation.
A health care provider must maintain an appropriate record, as
defined in part
5221.0100, subpart 1a, of any
treatment provided to a patient.
Subp.
3.
Nonoperative treatment.
Health care providers shall provide a trial of nonoperative
treatment before offering or performing surgical treatment unless the treatment
for the condition requires immediate surgery, unless an emergency situation
exists, or unless the accepted standard of initial treatment for the condition
is surgery.
Subp. 4.
Chemical dependency.
The health care provider shall maintain diligence to detect
incipient or actual chemical dependency to any medication prescribed for
treatment of the employee's condition. In cases of incipient or actual
dependency, the health care provider shall refer the employee for appropriate
evaluation and treatment of the dependency.
Subp. 5.
Referrals between health care
providers.
The primary health care provider directing the course of
treatment shall make timely and appropriate referrals for consultation for
opinion or for the transfer of care if the primary health care provider does
not have any reasonable alternative treatment to offer and there is a
reasonable likelihood that the consultant may offer or recommend a reasonable
alternative treatment plan. This subpart does not prohibit a referral for
consultation in other circumstances based on accepted medical practice and the
patient's condition.
A. Referrals from
consulting health care provider. If the consultant has reasonable belief that
another consultation is appropriate, that consultant must coordinate further
referral with the original treating health care provider unless the consultant
has been approved as the employee's treating health care provider. The
consultant is under no obligation to provide or recommend treatment or further
referral, if in the consultant's opinion, all reasonable and necessary
treatment has been rendered. The consultant shall in this situation refer the
employee back to the original treating health care provider for further
follow-up.
B. Information sent to
consultant. When a referring health care provider arranges for consultation or
transfer of care, except in cases of emergency, the referring health care
provider shall, with patient authorization, summarize for the consultant orally
or in writing the conditions of injury, the working diagnosis, the treatment to
date, the patient's response to treatment, all relevant laboratory and medical
imaging studies, return to work considerations, and any other information
relevant to the consultation. In addition, the referring health care provider
shall make available to the consultant, with patient authorization, a copy of
all medical records relevant to the employee's injury.
Subp. 6.
Communication between health
care providers and consideration of prior care.
A. Information requested by new health care
provider. Upon accepting for treatment a patient with a workers' compensation
injury, the health care provider shall ask the patient if treatment has been
previously given for the injury by another health care provider. If the patient
reports that treatment has been previously given for the injury by another
health care provider and if the medical records for the injury have not been
transferred, the new health care provider shall request authorization from the
employee for relevant medical records. Upon receipt of the employee
authorization, the new health care provider shall request relevant medical
records from the previous health care providers. Upon receipt of the request
for medical records and employee authorization, the previous health care
providers shall provide the records within seven working days.
B. Treatment by prior health care provider.
If the employee has reported that care for an injury has been previously given:
(1) Where a previous health care provider has
performed diagnostic imaging, a health care provider may not repeat the imaging
or perform alternate diagnostic imaging for the same condition except as
permitted in part
5221.6100.
(2) When a therapeutic modality employed by a
health care provider was no longer improving the employee's condition under
subpart
1, item B, or has been used
for the maximum duration allowed under parts
5221.6050 to
5221.6600, another health care
provider may not employ the same modality at any time thereafter to treat the
same injury except if one of the departures applies under subpart
8, after surgery, or for
treatment of reflex sympathetic dystrophy under part
5221.6305.
(3) It is also inappropriate for two health
care providers to use the same treatment modality concurrently.
C. Employee refusal. An employee's
refusal to provide authorization for release of medical records does not
justify repeat treatment or diagnostic testing. An insurer is not liable for
repeat diagnostic testing or other duplicative treatment prohibited by this
subpart.
Subp. 7.
Determinations of excessive treatment; notice of denial to health care
providers and employee; expedited processing of medical requests.
A. In addition to services deemed excessive
under part
5221.0500 and Minnesota Statutes,
section
176.136,
subdivision 2, treatment is excessive if:
(1)
the treatment is inconsistent with an applicable parameter or other rule in
parts
5221.6050 to 5221.6700:
or
(2) the treatment is consistent
with the parameters in parts
5221.6050 to 5221.6700. but is not
medically necessary treatment.
B. If the insurer denies payment for
treatment that departs from a parameter under parts
5221.6050 to
5221.6600, the insurer must
provide the employee and health care provider with written notice of the reason
for the denial and that the treatment rules permit departure from the
parameters in specified circumstances. If the insurer denies authorization for
proposed treatment after prior notification has been given under subpart
9, the insurer must provide
the employee and health care provider in writing with notice of the reason why
the information given by the health care provider does not support the proposed
treatment and notice of the right to review of the denial under subpart
9, item C. The insurer may
not deny payment for a program of chronic management that the insurer has
previously authorized for an employee, either in writing or by routine payment
for services, without providing the employee and the employee's health care
provider with at least 30 days' notice of intent to apply any of the chronic
management parameters in part
5221.6600 to future treatment. The
notice must include the specific parameters that will be applied in future
determinations of compensability by the insurer.
C. If the insurer denies authorization or
payment for treatment governed by parts
5221.6050 to
5221.6600, the health care
provider or the employee may request a determination from the commissioner or
compensation judge by filing a medical request or petition under chapter 5220
and Minnesota Statutes, sections
176.106,
176.2615, and
176.305.
The medical request may not be filed before completion of the managed care
plan's dispute resolution process, if applicable. If the health care provider
has notified the insurer of proposed treatment requiring prior notification
under subpart
9, the health care provider
or employee must describe or attach a copy of the notification, and any
response from the insurer, to the medical request filed with the department.
The insurer may, but is not required to, file a medical response where the
insurer's response to prior notification under subpart
9 has been attached to the
medical request. If the insurer elects to file a medical response in such
cases, it must be received within ten working days of the date the medical
request was filed with the department. The commissioner or compensation judge
may issue a decision based on written submissions no earlier than ten working
days after receipt of the medical request, unless a medical response has been
filed sooner.
D. A determination of
the compensability of medical treatment under Minnesota Statutes, chapter 176,
must include consideration of the following factors:
(1) whether a treatment parameter or other
rule in parts
5221.6050 to 5221.6700 applies to
the etiology or diagnosis for the condition;
(2) if a specific or general parameter
applies, whether the treatment is consistent with the treatment parameter and
whether the treatment was medically necessary as defined in part
5221.6040, subpart
10; and
(3) whether a departure from the applicable
parameter is or was necessary because of any of the factors in subpart
8.
Subp. 8.
Departures from
parameters.
A departure from a parameter that limits the duration or type
of treatment in parts
5221.6050 to
5221.6600 may be appropriate in
any one of the circumstances specified in items A to E. The health care
provider must provide prior notification of the departure as required by
subpart
9.
A. Where there is a documented medical
complication.
B. Where previous
treatment did not meet the accepted standard of practice and the requirements
of parts
5221.6050 to
5221.6600 for the health care
provider who ordered the treatment.
C. Where the treatment is necessary to assist
the employee in the initial return to work where the employee's work activities
place stress on the part of the body affected by the work injury. The health
care provider must document in the medical record the specific work activities
that place stress on the affected body part, the details of the treatment plan
and treatment delivered on each visit, the employee's response to the
treatment, and efforts to promote employee independence in the employee's own
care to the extent possible so that prolonged or repeated use of health care
providers and medical facilities is minimized.
D. Where the treatment continues to meet two
of the following three criteria, as documented in the medical record:
(1) the employee's subjective complaints of
pain are progressively improving as evidenced by documentation in the medical
record of decreased distribution, frequency, or intensity of
symptoms;
(2) the employee's
objective clinical findings are progressively improving, as evidenced by
documentation in the medical record of resolution or objectively measured
improvement in physical signs of injury; and
(3) the employee's functional status,
especially vocational activity, is objectively improving as evidenced by
documentation in the medical record, or successive reports of work ability, of
less restrictive limitations on activity.
E. Where there is an incapacitating
exacerbation of the employee's condition. However, additional treatment for the
incapacitating exacerbation may not exceed, and must comply with, the
parameters in parts
5221.6050 to
5221.6600.
Subp. 9.
Prior notification; health
care provider and insurer responsibilities.
Prior notification is the responsibility of the health care
provider who wants to provide the treatment in item A. Prior notification need
not be given in any case where emergency treatment is required.
A. The health care provider must notify the
insurer of proposed treatment in subitems (1) to (4) at least seven working
days before the treatment is initiated, except as otherwise provided in subitem
(4):
(1) for chronic management modalities
where prior notification is required under part
5221.6600;
(2) for durable medical equipment requiring
prior notification in parts
5221.6200, subpart
8; 5221.6205, subpart
8; 5221.6210, subpart
8; and 5221.6300, subpart
8;
(3) for any nonemergency inpatient
hospitalization or nonemergency inpatient surgery. A surgery or hospitalization
is considered inpatient if the patient spends at least one night in the
facility; and
(4) for treatment
that departs from a parameter limiting the duration or type of treatment in
parts
5221.6050 to
5221.6600. The health care
provider must notify the insurer within two business days after initiation of
treatment if the departure from a parameter is for an incapacitating
exacerbation or an emergency.
B. The health care provider's prior
notification required by item A may be made orally, or in writing, and shall
provide the following information, when relevant:
(1) the diagnosis;
(2) when giving prior notification for
chronic management modalities, durable medical equipment, or inpatient
hospitalization or surgery required by item A, subitems (1) to (3), whether the
proposed treatment is consistent with the applicable treatment parameter;
and
(3) when giving prior
notification for treatment that departs from a treatment parameter, or
notification of treatment for an incapacitating exacerbation or emergency, the
basis for departure from any applicable treatment parameter specified in
subpart
8; the treatment plan,
including the nature and anticipated length of the proposed treatment; and the
anticipated effect of treatment on the employee's condition.
C. The insurer must provide a
toll-free facsimile and telephone number for health care providers to provide
prior notification. The insurer must respond orally or in writing to the
requesting health care provider's prior notification of proposed treatment in
item A within seven working days of receipt of the request. Within the seven
days, the insurer must either approve the request, deny authorization, request
additional information, request that the employee obtain a second opinion, or
request an examination by the employer's physician. A denial must include
notice to the employee and health care provider of the reason why the
information given by the health care provider in item B does not support the
treatment proposed, along with notice of the right to review of the denial
under subitem (3).
(1) If the health care
provider does not receive a response from the insurer within the seven working
days, authorization is deemed to have been given.
(2) If the insurer authorizes the treatment,
the insurer may not later deny payment for the treatment authorized.
(3) If the insurer denies authorization, the
health care provider or employee may orally or in writing request that the
insurer review its denial of authorization.
The insurer's review of its denial must be made by a currently
licensed registered nurse, medical doctor, doctor of osteopathy, doctor of
chiropractic, or a person credentialed by a program approved by the
commissioner of Labor and Industry. The insurer may also delegate the review to
a certified managed care plan under subpart
10. In lieu of or in
addition to the insurer's review under this subitem, the insurer may request an
examination of the employee under subitem (4), (5), or (6) and the requirements
of those subitems apply to the proposed treatment. Unless an examination of the
employee is requested under subitem (4), (5), or (6), the insurer's
determination following review must be communicated orally or in writing to the
requester within seven working days of receipt of the request for
review.
Instead of requesting a review, or if the insurer maintains its
denial after the review, the health care provider or the employee may file with
the commissioner a medical request or a petition for authorization of the
treatment under subpart
7, item C, or except as
specified in subitem (4), (5), or (6), may proceed with the proposed treatment
subject to a later determination of compensability by the commissioner or
compensation judge.
(4) If
the insurer requests an examination of the employee by the employer's
physician, the health care provider may elect to provide the treatment subject
to a determination of compensability by the commissioner or compensation judge
under subpart
7, item B. However, the
health care provider may not provide nonemergency surgery where the insurer has
requested an examination for surgery except as provided in subitems (5) and
(6), and may not provide continued passive care modalities where prior approval
by the insurer, commissioner, or compensation judge is required under parts
5221.6200, subpart
3, item B, subitem (2);
5221.6205, subpart
3, item B, subitem (2);
5221.6210, subpart
3, item B, subitem (2); and
5221.6300, subpart
3, item B, subitem
(2).
(5) If prior notification of
surgery is required under item A, subitem (3), the insurer may require that the
employee obtain a second opinion from a physician of the employee's choice
under Minnesota Statutes, section
176.135,
subdivision 1a. If within seven working days of the prior notification the
insurer notifies the employee and health care provider that a second opinion is
required, the health care provider may not perform the nonemergency surgery
until the employee provides the second opinion to the insurer. Except as
otherwise provided in parts
5221.6200, subpart
6, items B and C; 5221.6205,
subpart
6, items B and C; 5221.6210,
subpart
6, items B and C; 5221.6300,
subpart
6, item B; and 5221.6305,
subpart
3, item B, if the insurer
denies authorization within seven working days of receiving the second opinion,
the health care provider may elect to perform the surgery, subject to a
determination of compensability by the commissioner or compensation judge under
subpart
7.
(6) In any case where prior notification of
proposed surgery is required, the insurer may elect to obtain an examination of
the employee by the employer's physician under Minnesota Statutes, section
176.155, sometimes
referred to as an "independent medical examination." If the insurer notifies
the employee and health care provider of the examination within seven working
days of the provider's notification, the proposed nonemergency surgery may not
be provided pending the examination. However, after 45 days following the
insurer's request for an examination, the health care provider may elect to
proceed with the surgery, subject to a determination of compensability by the
commissioner or compensation judge under subpart
7.
(7) The insurer's request for additional
information must be directed to the requesting health care provider and must
specify the additional information required that is necessary to respond to the
health care provider's notification of proposed treatment. The proposed
treatment may not be given until the provider provides reasonable additional
information. Once the additional information has been received, the insurer
must respond within seven working days according to subitems (1) to
(6).
Subp.
10.
Certified managed care plans.
The insurer may delegate responsibility for the notices
required in subpart
7, item B, and the response
to prior notification under subpart
9, to the certified managed
care plan with which the insurer has contracted to manage the employee's
medical treatment under Minnesota Statutes, section
176.135,
subdivision 1f. Alternatively, the managed care plan may act as an intermediary
between the treating health care provider and the insurer. In either case, the
notices and time periods in subparts
7,
8, and
9 also apply to the managed
care plan. Where the insurer has delegated responsibility to the managed care
plan, the insurer may not later deny treatment authorized by the plan.
Subp. 11.
Outcome
studies.
The commissioner shall perform outcome studies on the treatment
modalities in parts
5221.6200 to
5221.6600. The modalities to be
studied shall be selected in consultation with the Workers' Compensation
Medical Services Review Board. The commissioner may require health care
providers who use these modalities to prospectively gather and report outcome
information on patients treated, with necessary consent of the employee. The
health care providers shall report the outcome information on the modalities in
parts
5221.6200 to
5221.6600 on a form prescribed by
the commissioner, which may include:
A. the name of the health care
provider;
B. the name of the
patient, date of injury, date of birth, gender, and, with patient permission,
level of education and social security number;
C. the name of the workers' compensation
insurer and managed care plan, if any;
D. the pretreatment and posttreatment
employment status;
E. the nature of
treatment given before and after the treatment being studied for the same
condition;
F. the diagnosis,
symptoms, physical findings, and functional status before and after the
treatment being studied for the same condition; and
G. the presence or absence of preexisting or
concurrent conditions.
Statutory Authority: MS s
176.103;
176.83
