Current through all regulations passed and filed through September 16, 2024
Reimbursement for lumbar
fusion surgery for treatment of allowed conditions in a claim resulting from an
allowed industrial injury or occupational disease shall be limited to claims in
which current best medical practices as implemented by this rule are
followed.
This rule governs the bureau's reimbursement of lumbar fusion
surgery to treat a work related injury or occupational disease. It is not meant
to preclude, or substitute for, the surgeon's responsibility to exercise sound
clinical judgment in light of current best medical practices when treating
injured workers.
A provider's failure to comply with the requirements of this
rule may constitute endangerment to the health and safety of injured workers,
and claims involving lumbar fusion surgery not in compliance with this rule may
be subject to peer review by the bureau of workers' compensation stakeholders'
health care quality assurance advisory committee (HCQAAC) pursuant to rule
4123-6-22 of the Administrative
Code or other peer review committee established by the bureau.
Medical treatment reimbursement requests (on form C-9 or
equivalent) for lumbar fusion surgery are not subject to dismissal by the MCO
pursuant to paragraph (F)(7) of rule
4123-6-16.2 of the
Administrative Code.
(A) Prerequisites
to consideration of lumbar fusion surgery.
Except as otherwise provided in paragraph (A)(4) of this rule,
authorization for lumbar fusion shall be considered only in cases in which the
following criteria are met:
(1)
Conservative care.
(a) The injured worker must
have had at least sixty days of conservative care for low back pain, with an
emphasis on:
(i) Physical
reconditioning;
(ii) Avoidance of
opioids, when possible; and
(iii)
Avoidance of provider catastrophizing the explanation of lumbar MRI
findings.
(b) The injured
worker's comprehensive conservative care plan may include, but is not limited
to, one or more of the following:
(i) Relative
rest/ice/heat;
(ii)
Anti-inflammatories;
(iii) Pain
management / physical medicine rehabilitation program;
(iv) Chiropractic / osteopathic
treatment;
(v) Physical medicine
treatment as set forth in rule
4123-6-30 of the Administrative
Code;
(vi) Interventional spine
procedures / injections.
(2) The operating surgeon requesting
authorization for lumbar fusion surgery must have personally evaluated the
injured worker on at least two occasions prior to requesting authorization for
lumbar fusion surgery.
(3) The
injured worker must have undergone a comprehensive evaluation, coordinated by
both the injured worker's physician of record or treating physician and the
operating surgeon, in which all of the following have been documented:
(a) Utilization and correlation of all of the
following tools:
(i) Visual analog scale
(VAS);
(ii) Pain diagram;
(iii) Oswestry low back disability
questionnaire.
(b) A
comprehensive orthopedic / neurological examination, including documentation of
all of the following categories:
(i)
Gait;
(ii) Spine (deformities,
range of motion, palpation);
(iii)
Hips and sacroiliac joints;
(iv)
Motor;
(v) Sensation;
(vi) Reflexes;
(vii) Upper motor neuron signs.
(c) Diagnostic testing.
(i) Lumbar X-rays (including flexion
and extension
views)
and a
lumbar MRI or lumbar CT (with or
without myelography) must be performed;
(ii) Electromyography (EMG) / nerve
conduction study (NCS) may be performed if questions still remain during
surgical planning.
(d)
Discussion and consideration of opportunities for vocational
rehabilitation.
(e) Review of
current and previous medications taken.
(i) If
opioid management is in process, review for best practices;
(ii) Consider impact of surgery on opioid
load.
(f) Health
behavioral assessment (pre-surgical).
Biopsychosocial factors that may affect treatment of the
injured worker's allowed lumbar conditions are considered modifiable conditions
that may change the need for surgery or improve surgical outcomes if
appropriately addressed, and must be addressed if identified in the assessment.
The health behavioral assessment and any identified interventions may be
ordered by the injured worker's physician of record or treating physician, or
the operating surgeon.
(g)
Accounting and assessment of the following co-morbidities to stratify
additional associated risks:
(i)
Smoking;
(ii) Body mass index
(BMI);
(iii) Diabetes;
(iv) Coronary artery disease;
(v) Peripheral vascular disease.
The co-morbidities indicated above are considered modifiable
conditions that may improve surgical outcomes if appropriately addressed, and
must be addressed if identified in the assessment.
(h) The injured worker and the physician of
record, the treating physician, or the operating surgeon must have reviewed and
signed the educational document, "What BWC Wants You to Know About Lumbar
Fusion Surgery," attached as an appendix to this rule.
(4) The prerequisites to consideration of
lumbar fusion surgery set forth in paragraphs (A)(1) to (A)(3) of this rule may
be waived in cases of:
(a) Progressive
functional neurological deficit;
(b) Spinal fracture;
(c) Tumor;
(d) Infection;
(e) Trauma care;
(f) Emergency as defined in rule
4123-6-01 of the Administrative
Code; and/or
(g) Other catastrophic
spinal pathology causally related to the injured worker's allowed
conditions.
(B)
Authorization for lumbar fusion surgery where the injured worker has no prior
history of lumbar surgery at the level for which the
fusion is requested.
(1) Authorization
for lumbar fusion shall be considered in cases where the injured worker has no
prior history of lumbar surgery only when the injured worker remains highly
functionally impaired despite a trial of at least sixty days of conservative
care as provided in paragraph (A)(1)(a) of this rule (unless waived pursuant to
paragraph (A)(4) of this rule) and one or more of the following are present:
(a) Mechanical low back pain with instability
of the lumbar segment and no history of lumbar surgery.
(b) Spondylolisthesis of twenty-five per cent
or more with one or more of the following:
(i)
Objective signs/symptoms of neurogenic claudication;
(ii) Objective signs/symptoms of unilateral
or bilateral radiculopathy, which are corroborated by neurologic examination
and by MRI or CT (with or without myelography);
(iii) Instability of the lumbar
segment.
(c) Lumbar
radiculopathy with stenosis and bilateral spondylolysis.
(d) Lumbar stenosis necessitating
decompression in which facetectomy of greater than or equal to fifty per cent
or more is required.
(e) Primary
neurogenic claudication and/or radiculopathy associated with lumbar spinal
stenosis in conjunction with spondylolisthesis or lateral translation of three
mm or greater or bilateral pars defect.
(f) Degenerative disc disease (DDD)
associated with significant instability of the lumbar segment.
(g) Spinal stenosis, disc herniation, or
other neural compressive lesion requiring extensive, radical decompression with
removal of greater than fifty per cent of total facet volume at the associated
level.
The surgeon must document why the surgical lesion would require
radical decompression through the pars interarticularis (critical stenosis,
recurrent stenosis with extensive scarring, far lateral lesion).
(2) For purposes of this
paragraph, instability of the lumbar segment is defined as at least four mm of
anterior/posterior translation at L3-4 and L4-5, or five mm of translation at
L5-S1, or eleven degrees greater end plate angular change at a single level,
compared to an adjacent level.
(C) Request for lumbar fusion surgery where
the injured worker has a history of prior lumbar surgery
at the level for which the fusion is requested.
(1) If a trial of at least sixty days of
conservative care as provided in paragraph (A)(1)(a) of this rule has failed to
relieve symptoms (or has been waived pursuant to paragraph (A)(4) of this rule)
and the injured worker has had a prior laminectomy, discectomy, or other
decompressive procedure at the same level, lumbar fusion should be considered
for approval only if the injured worker has one or more of the following:
(a) Mechanical (non-radicular) low back pain
with instability at the same or adjacent levels.
(b) Mechanical (non-radicular) low back pain
with pseudospondylolisthesis, rotational deformity, or other condition leading
to a progressive, measureable deformity.
(c) Objective signs/symptoms compatible with
neurogenic claudication or lumbar radiculopathy that is supported by EMG/NCS,
lumbar MRI, or CT and detailed by a clinical neurological examination in the
presence of instability of three mm lateral translation with at least two prior
decompression surgeries at the same level.
(d) Evidence from post laminectomy structural
study of either:
(i) One hundred per cent loss
of facet surface area unilaterally; or
(ii) Fifty per cent combined loss of facet
surface area bilaterally.
(e) Documented pseudoarthrosis or nonunion,
with or without failed hardware, in the absence of other neural compressive
lesion.
(2) For purposes
of this paragraph, instability of the lumbar segment is defined as at least
four mm of anterior/posterior translation at L3-4 and L4-5, or five mm of
translation at L5-S1, or eleven degrees greater end plate angular change at a
single level, compared to an adjacent level.
(D) Lumber fusion surgical after care.
The physician of record or treating physician must follow the
injured worker until the injured worker has reached maximum medical improvement
(MMI) for the allowed lumbar conditions.
The operating surgeon must follow the injured worker until the
injured worker has reached a plateau relative to the lumbar fusion and the
surgeon has determined no further surgical related treatment is medically
necessary.
(1) In the first six months
post-operatively, the injured worker must be seen by both the physician of
record or treating physician and the operating surgeon at least every two
months to monitor the injured worker's progress, rehabilitation needs,
behavioral patterns or changes, and return to work willingness and/or status.
During this period, the physician of record or treating
physician and the operating surgeon shall determine the following:
(a) Fusion status;
(b) Pain and functional status;
(c) MMI status of injured worker;
(d) Residual level of functional
capacity;
(e) Appropriateness for
vocational rehabilitation.
(2) From six months to one year
post-operatively, if the injured worker continues to experience significant
functional impairment despite the lumbar fusion, the following actions are
recommended:
(a) Pain and functional status
(repeat VAS / pain diagram / Oswestry)
(b) Repeat baseline orthopedic / neurological
examination;
(c) Repeat health
behavioral assessment;
(d) Revisit
appropriate diagnostic imaging.
(e)
Coordinate with MCO to develop a plan of care / return to functional status.
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Appendix
