Adjusters May Authorize The Following:
Routine care for common injuries, such as:
• Simple Fractures
• Lacerations/Abrasions/Contusions
• Foreign bodies in the eye
• Sprain/Strain
• Basic DME (splints, crutches, cane, walker, standard wheelchair rental, off-the-shelf braces, walking boots, slings, hot & cold packs
• Basic Tens Unit in the first 60 days of injury
• Follow up exams
• Referral to Specialist for consult on accepted body part(s), including Pain Management.
• Psychological visits (up to 12) on accepted diagnosis.
• Cognitive Behavioral Therapy and Biofeedback for Chronic Pain cases up to 12 visits.
NOTE: Request for change in PTP is not a UR request.
Physical Medicine & Rehabilitation
• Up to a total of 24 Physical/Occupational therapy visits
• Up to a total of 24 Physical Therapy or Occupational Therapy visits for Post-Surgical rehabilitation
• Up to a total of 24 Chiropractic visits
• Up to a total of 24 Acupuncture visits
• Up to a total of 12 Aquatic visits
• On future medical claims, if documented aggravation, up to 12 PT/OT/Chiro visits may be authorized, if warranted.
Pharmacy Benefit Management
Must be on California’s DWC Formulary.
• Over the Counter Medications that are appropriate to Diagnosis
• Generic Medications that are appropriate to Diagnosis
• Short Acting Narcotics/Opiates such as Norco, Vicodin, Percocet, Codeine and Hydrocodone: Up to 30 days.
• Anti-inflammatory meds (NSAIDS): Up to 90 days.
• Antibiotics, if industrial in nature
• 1 Time 30-day authorization of formulary prescription drugs; except, Opioids/Narcotics.
• If accepted Diabetic claim, authorize 1-year supply of insulin and supplies and only send to UR after initial 1-year period if quantities or supplies have changed. If no change, authorize for another 12-month period. No UR needed.
• If accepted asthma/lung claim, authorize 1-year supply of meds, oxygen, supplies. If prescription remains the same, authorize again for a 12-month period. No UR needed. Except if Fluticasone Propionate Powder, UR is required for each script. Analyst must work with prescribing physician for a comparable drug generic. This medication costs $15,500.00.
• All CA Exempt Medications on MTUS Drug Formulary. Please note: DWC will periodically make updates to the MTUS Drug Formulary.
• Antibiotics – covered in the first 30 days from DOI
• NSAIDS (except topical and combo NSAIDs)
• Anti-Inflammatory Meds (except rheumatology meds such as Arava, Enbrel and Humira)
• Non-narcotic Analgesics
• Anticonvulsants Antihistamines and Beta Agonists
• Laxatives
• Acid Reducers and Intestinal Acidifiers
• Anti-Ulcer (Misc. – Carafate, Cytotec)
• Topical Analgesics (OTC brands only such as Aspercreme, Ben-Gay, Bioflex, Salonpas, Bioefreeze, etc.)
• Topical: Antibiotics, Antipruritics, Burn Products, Anti-Infectives, Corticosteroids, Skin Cleansers, Emollients, Scabicides and Wound Care Products
• Antidepressants – up to initial 30-day supply
• Corticosteroids (non-topical) – up to initial 30-day supply
• Hypnotics – up to initial 30-day supply
• Muscle Relaxers (except Soma, Soma Compound and Amrix) – up to initial 30-day supply
• Ophthalmic – All types (on accepted eye injury claims)
• Otics – All types (on accepted ear injury claims)
• Short-Acting Opioids/Narcotic Analgesics – Authorized up to 4 days (Excludes Buprenex, Subutex, Suboxone, Opana, Methadone, Actiq, Fentora, Fentanyl powder, Talwin NX, and Stadol)
• Narcotic combinations – Authorized up to 4 days (Example: Percocet, Lortab, Vicodin, Norco)
• If necessary due to medical need, Norco may be dispensed an additional 26 days.
Diagnostic/Radiology/Diagnostic Testing
• Echo Cardiogram
• Stress Test
• Pre-Op Exam
• Blood Work Up
• MRI/CT/Bone Scan to rule out fracture, infection, tear or tumor (w/wo contrast)
• Initial electrodiagnostic testing (EMB/NCS)
• Initial x-rays
• Initial Cat Scan
• Initial MRI (w/wo contrast)
• If no improvement through treatment due to an aggravation of an accepted claim, ok to authorize in-house 2nd MRI or CT.
• Routine Pre-Op Testing (CBC, Chemistry Panel, Chest X-ray, EKG, COVID-19)
• EMG/NCV: with documented neurological deficit (CTS/cubital tunnel syndrome, cervical/lumbar radiculopathy); after 3 weeks of conservative treatment without documented neurological deficit.
• Biopsy and Pathology (on accepted skin cancer/condition claims)
Durable Medical Equipment
• Basic DME (splints, crutches, cane, walker, standard wheelchair rental, off-the-shelf braces, walking boots, slings, hot & cold packs
• Rental of CPM (Continuous Passive Motion) machines; for Total Knee Replacement, ACL Repair, Rotator Cuff repair for up to 21 days only.
• 3-in-1 commode chair on surgeries
• Non-custom Orthotics for Plantar Fasciitis
• All DME listed on post-surgical Adjuster Trigger List.
• Basic Tens Unit on new injuries for up to 3 months
• CPAP if testing positive for sleep apnea and claim is accepted
• Supplies for UR APPROVED DME.
• Hearing Aids and Supplies on Lifetime Hearing Loss claims every 4-5 years
Injections with positive findings
• Up to 3 Trigger Point Injections
• Up to 3 Cortisone steroid injections to one joint per year
• Up to 1 Lumbar Epidural Injections
• Up to 1 Synvisc Injections
• 1 Facet Injection
Surgery
• Routine pre-operative testing ordered by Surgeon; ECG, EKG, Chest X-Ray, Chemistry Panel, CBC
• Routine surgical removal of Non-Spine hardware
• Initial hernia repair (on accepted injury only)
• Rotator Cuff Repair with positive MRI findings
• Meniscus Repairs with positive MRI findings
• Arthroscopic surgery of Knee and Shoulder
• Carpal Tunnel or Ulnar Release with mod/severe NCV study and/or positive response to cortisone injections and positive MRI findings.
• Pain/Morphine Pump Refills (when implant was originally approved)
• Biopsies (cancer claims)
• Pacemaker Checks
• Foreign Body Removal, and Incision and Drainage (I&Ds)
• Hardware Removal – Non-Spine
Note: All spinal and cervical surgeries must go through UR.
Miscellaneous
• Transfers to Home Health/Skilled Nursing Facilities on urgent post-op heart, severe lower extremity injury,COVID-19 recovery, back and neck surgeries
• Specialist Consults for accepted body parts
• Psychiatric/Psychological evaluations
• Transfers to Inpatient Rehab or Skilled Nursing Facility for post-op Rehab up to 30 days.
If you’re unsure of a procedure please email karin@westernintegratedcare.com or dawn@westernintegratedcare.com.
|
Adjusters Must Refer The Following To Utilization Review:
• Anything considered experimental, investigational, questionable, or unfamiliar.
• If the treatment does not fit the injury/diagnosis.
• Any prescription drug with a cost over $500.
• All Non-Medical exercise or treatment programs including: Reflexology, Aerobics, Personal Trainers, Pilates.
• Weight loss programs
• All Dental Services – Send to WIC for handling.
• PRP Injections
• Compound Creams
Physical Medicine & Rehabilitation
• Functional Capacity Evaluations (FCE)
• Computerized Strength/Range of Motion Testing
• Massage Therapy
• Gym Memberships
• Biofeedback
• MAUs
• Feldenkrais or Pilates
• Detoxification Programs
• Shock Wave Therapy
Prescription Drugs
The following medications must be sent for Utilization Review, even on 1st fill:
• Compound Meds and Creams
• Medical Foods and Drinks
• Opana
• Long Acting Narcotics/Opiates such as Fentanyl (Actiq/Duragesic), MS Contin/Kadian
• Use of Opiate longer than 120 days.
• Any prescription drug with a cost over $1,000.00. Examples include but not limited to: Abilify, Sovaldi, Fluticasone Propionate Powder, Embrel, Gleevec, Fentora, Capecitabine, Humira
• Prescriptions for lifestyle drugs, such as Viagra.
• Over the counter medications (OTC) exceeding $200 or if not medically substantiated.
• THC
• Non-Exempt Drugs
Diagnostic/Radiology/Diagnostic Testing
• Discogram
• Myelogram (Invasive CT of Spine)
• Repeat MRI within one year of last MRI unless surgery is being considered.
• Multiple site MRI’s; unless body parts are accepted.
• Repeat MRI’s unless a documented aggravation.
• Electrodiagnostic Testing beyond initial NCV or EMG. All Surface EMGs’ (SEMG) must go through UR.
Durable Medical Equipment
Below must go through UR:
• Electrical stimulation devices such as:
TENS or H-Wave, unless Basic Tens Unit on new injuries for up to 3 months only, then UR is needed.
• Interferential Stimulator
• All other DME not listed on approval list.
• Custom and/or special braces.
• Dynamic Splinting
• Spinal unloading devices
• Rental of CPM machines other than for Total Knee Replacement, ACL repair or Rotator Cuff repair
• Rental of CPM for more than a 30-day period for above surgeries
• Beds, spas and power mobility devices (scooters, power chairs, etc.)-unless rental
• Cold Therapy/Compression devices unless for Surgeries.
• Lymphedema Pump
Injections
• Cortisone steroid injections-over 3 injections to one joint per year
• Epidural Injections-over 3 injections with nerve root compression on MRI
• Facet Injections-beyond 1
• Trigger Point Injections-over 3 injections or 6 visits
• Selective Nerve Root Blocks (spine)
• Any disc procedure—IDET (Intradiskal Electrothermal Therapy), nucleoplasty, laser discectomy
• Any radio frequency (RF) procedure of spine
• Epidural adhesiolysis or chemical lysis procedures (breaking up adhesions in spine)
• Botox Injections
Surgery
• All requests for surgeries not listed under adjuster authorizations
• All spinal and cervical surgeries must go through UR.
• All other shoulder, knee and ankle surgeries not listed.
• Hardware removal-spine
• Dorsal Column Stimulators (Spinal Cord Stimulators
• Implantable Pain Pumps
Miscellaneous
• Detoxification Programs
• Chronic Pain Programs
• Home Health Care and Attendant Care; unless post-surgery.
• Functional Restoration Programs
• Weight Loss Programs (other than Weight Watchers)
• Weight Loss Surgery
• Sleep Studies
• Discograms/Arthrogram/Myelogram
• Drug Testing: Unless Routine.
• Any procedures that may be experimental or investigational
• All Spinal Injection Procedures, such as:
Nerve Root or Facet Blocks(beyond 1st block)
|
