Current through Register Vol. XLI, No. 50, December 13, 2024
Section 85-20-4 - Adoption of Standards and Acceptance of Rules4.1. The treatment guidelines, standards, protocols, and limitations thereon provided for the injuries and diseases listed in this section are designed to assist health care providers in the evaluation and treatment of injured workers. The provisions of this Rule are not intended to strictly dictate results and it is recognized that there may be extraordinary cases that require treatments in addition to the treatments set forth in this Rule. However the treatments and limitations on treatments set forth in this Rule are presumed to be medically reasonable and treatments in excess of those set forth in this rule are presumed to be medically unreasonable. A preponderance of evidence, including but not limited to, detailed and documented medical findings, peer reviewed medical studies, and the elimination of causes not directly related to a compensable injury or disease, must be presented to establish that treatments in excess of those provided for in this Rule are medically reasonable. To receive reimbursement from the Commission, insurance commissioner, self-insured employer or private carrier, whichever is applicable, for treatment in excess of that provided for in this Rule, all providers must thoroughly document and explain the action taken and the basis for the deviation from this Rule and shall receive authorization before providing said treatment.4.2. Except as provided for in section 5.11 of this Rule, providing treatment to an injured worker, filling prescriptions for an injured worker, and/or acceptance of payment for treatment, devices, or medications provided to an injured worker constitutes acceptance by the medical provider of the Commission's or Insurance Commissioner's rules and fee schedules.4.3. Failure of the medical provider to timely submit appropriately completed forms, failure to comply with this Rule or any fee schedule or billing guideline, as may be from time to time amended, and any attempt to seek reimbursement in excess of the levels provided for in this Rule may be considered as an abusive practice for purposes of W. Va. Code § 23-4-3c and may be considered as evidence of conduct in violation of W. Va. Code § 61-3-24g. All medical reports and fee bills must be signed by the medical vendor rendering the services or his authorized representative. If the report or bill is not submitted electronically, the medical vendor's name must be legibly printed or typed beneath the signature.