W. Va. Code R. § 85-20-46

Current through Register Vol. XLI, No. 50, December 13, 2024

Section 85-20-46 - Treatment Guidelines: Physical Medicine

46.1. Principles for use of physical medicine:

a. Physical medicine should be initiated as early as the day of injury; indications for and focus of (early) intervention include:

1. Acute management of pain and spasms;

2. Use of passive modalities as adjunct to active treatment;

3. Manual therapy for restoring joint function;

4. Instruction in range of motion and stretching exercises;

5. Assessment of return to work readiness and identifying necessary work modifications;

6. Injured worker education in healing process, body mechanics, proper resting positions, and home treatment program; and

7. Time frames may range from one visit to daily visits in accordance with applicable treatment guidelines.

b. Evaluations and treatments authorized by the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, must be provided by professionals licensed to perform such activities.

c. Initiation of treatment may not be indicated when:

1. Few objectively measured deficits are found on evaluations;

2. Subjective complaints of pain are the only finding;

3. Pain behaviors are interfering with the return to work process; and

4. Injured worker is not compliant with the treatment plan.

d. Inappropriate and medically unsupported treatment is the exclusive use of passive modalities throughout the course of treatment.

e. Exercise programs are progressively increased to include strengthening and conditioning exercises. Any work simulation activities (also gradually increased) should focus on essential work tasks (pushing, pulling, lifting, etc.). Time frames may range from 1 to 4 hours per day, 3 to 5 days per week in accordance with above treatment guidelines.

f. Progress reports to the referring physician, the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, and the employer should identify continuing complaints, progress made, further rehabilitation needs, and level of return to work readiness. An injured worker may continue in therapy, if indicated, after return to work in accordance with applicable treatment guidelines.

46.2. Treatment limitations. Physical medicine treatment shall not exceed 10 visits in the initial 14 days and must decrease in frequency thereafter. In no case shall the treatment exceed 16 visits in the initial 30 days or 12 visits in the second 30 days.

46.3. If physical medicine care continues to the 30^th day and the injured worker has not returned to work, the treating physician may arrange a consultation for a second opinion. Reimbursement for care past the 45^th day shall be disallowed unless the consulting physician recommends further care.

46.4. If care continues to the 30^th day and the injured worker lost no time or is back to work, shows significant documented functional and clinical signs of improvement, and has not reached maximum medical improvement, continued care is appropriate. Such care shall not exceed the 60^th day unless otherwise expressly authorized by this Rule.

46.5. Injured workers with complicating factors which have prevented a return to work by the 60^th day require active case management by the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, within the parameters of this Rule. Independent medical evaluator guidance may be requested by the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, in its sole discretion.

46.6. Treatment beyond 28 dates of service (within 60 days) is limited to a maximum of 5 treatments over one additional 30-day period and requires Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, authorization. Authorization requires the worker has a history of surgery or fracture in the involved area, and either 1) the worker has returned to work or 2) modified work is not available.

46.7. Workers who have returned to work, reached maximum medical improvement and experience flare-ups of their injuries, due to job-related activities, may be treated a maximum of 4 times over a 2-week period. The Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, will reimburse a maximum of 12 treatments for work related flare-ups within 14 months of the date of injury.

46.8. Reimbursement shall be disallowed for any treatment rendered after the injured worker reaches maximum medical improvement unless otherwise expressly authorized by this Rule.

W. Va. Code R. § 85-20-46