Current through all regulations passed and filed through September 16, 2024
This rule governs the bureau's
reimbursement for services in an allowed claim related to concussion. It is not
meant to preclude, or substitute for, the health care provider's responsibility
to exercise sound clinical judgment in light of current best medical practices
when treating injured workers.
(A)
As used in this
rule, "concussion" means a type of traumatic brain injury induced by external
force, which might include a bump or blow to the head, or a jolt or hit to the
body, which causes the brain to bounce around or twist in the skull, causing
chemical changes in the brain and sometimes stretching and damaging brain
cells.
(1)
Concussion is manifest by at least one of the
following:
(a)
Any alteration in mental state at the time of the accident
(feeling dazed, disoriented, or confused);
(b)
Any period of
loss of consciousness;
(c)
Any loss of memory for events immediately before or
after the accident; or
(d)
Focal neurological deficit that may or may not be
transient, but where the severity of the injury does not exceed the
following:
(i)
A loss of consciousness for approximately thirty minutes or
less;
(ii)After thirty minutes, an initial Glasgow Coma Score of
13-15; or
(iii)Post-traumatic amnesia not greater than twenty-four
hours.
(2)
A concussion may
involve different symptoms, clinical profiles and subtypes, and different
recovery trajectories, which may be influenced by a variety of risk factors.
Kontos, Anthony P. and Michael W. Collins. Concussion: a clinical profile
approach to assessment and treatment. Washington, DC: American Psychological
Association (2018), p.5. Adapted with permission.
(3)
In concussion,
even though by definition brain injury has occurred, standard imaging studies
such as CT scan and MRI will commonly be normal.
(B)
As used in this
rule, "clinical domains" related to concussion means the following group of
signs or symptoms related to a specific body part or system:
(1)
Anxiety and mood:
including ruminating thoughts, difficulty concentrating, hypervigilance, or
fastidiousness.
(2)
Vestibular: including impaired balance and equilibrium,
dizziness, nausea, or environmental sensitivity,
(3)
Ocular: including
impaired vision and visual tracking, impaired comprehension, trouble focusing,
or distractibility.
(4)
Sleep: including trouble falling asleep or sleeping
more or less than usual.
(5)
Cervical: including neck pain, stiffness, or reduced
range of motion.
(6)
Cognitive fatigue: including impaired thinking
abilities, feeling slow or "one step behind", physical and mental fatigue,
general headache, or sleep disturbance.
(7)
Headache
(migraine, cervicogenic, and tension headache): including variable and
intermittent severe headache, nausea, photosensitivity, or vestibular
migraine.
(8)
Cognitive impairment: including impairment in
attention, memory, executive function, language processing, or visual
perception and processing.
(C)
Notwithstanding
any provision to the contrary in any other rule of the bureau, medical
treatment reimbursement requests relating to the clinical domains set forth in
paragraph (B) of this rule, submitted within six months from the date of
injury, for treatment not to exceed six months from the date of injury, may be
authorized in an allowed claim, without disclaimer, when:
(1)
The documented
mechanism of injury in the claim included a bump or blow to the head, or a jolt
or hit to the body: and
(2)
Signs or symptoms related to the clinical domains have
manifested within six weeks of the date of injury; and
(3)
The requested
medical treatment is determined to be medically necessary and appropriate, and
reasonably related to treatment of concussion, based on the medical
evidence.
(D)
When concussion or other conditions relating to the
clinical domains set forth in paragraph (B) of this rule and treated pursuant
to paragraph (C) above are determined to require ongoing treatment beyond six
months, the physician of record or treating provider may request these
conditions be additionally allowed in the claim.
