WAC 296-20-03001   Treatment requiring authorization.  Certain treatment procedures require authorization by the department or self-insurer. Requests for authorization must include a statement of: The condition(s) diagnosed; ICD-9-CM codes; their relationship, if any, to the industrial injury/exposure; an outline of the proposed treatment program, its length and components, procedure codes, and expected prognosis; and an estimate of when treatment would be concluded and condition stable.

     (1) Office calls in excess of the first twenty visits or sixty days whichever occurs first.

     (2) The department may designate those inpatient hospital admissions that require prior authorization.

     (3) X ray and radium therapy.

     (4) Diagnostic studies other than routine X-ray and blood or urinalysis laboratory studies.

     (5) Myelogram and discogram in nonemergent cases.

     (6) Physical therapy treatment beyond initial twelve treatments as outlined in chapters296-21, 296-23, and 296-23A WAC.

     (7) Diagnostic or therapeutic injection. Epidural or caudal injection of substances other than anesthetic or contrast solution will be authorized under the following conditions only:

     (a) When the worker has experienced acute low back pain or acute exacerbation of chronic low back pain of no more than six months duration.

     (b) The worker will receive no more than three injections in an initial thirty-day treatment period, followed by a thirty-day evaluation period. If significant pain relief is demonstrated one additional series of three injections will be authorized. No more than six injections will be authorized per acute episode.

     (8) Home nursing, attendant services or convalescent center care must be authorized per provisions outlined in WAC 296-20-091 or 296-23-246.

     (9) Provision of prosthetics, orthotics, surgical appliances, special equipment for home or transportation vehicle; custom made shoes for ankle/foot injuries resulting in permanent deformity or malfunction of a foot; TNS units; masking devices; hearing aids; etc., must be authorized in advance as per WAC 296-20-1101 and 296-20-1102.

     (10) Biofeedback program; pain clinic; weight loss program; psychotherapy; rehabilitation programs; and other programs designed to treat special problems must be authorized in advance. Refer to the department's medical aid rules and fee schedules for details.

     (11) Prescription or injection of vitamins for specific therapeutic treatment of the industrial condition(s) when the attending doctor can demonstrate that published clinical studies indicate vitamin therapy is the treatment of choice for the condition. Authorization for this treatment will require presentation of facts to and review by department medical consultant.

     (12) Injections of anesthetic and/or anti-inflammatory agents into the vertebral facet joints will be authorized to qualified specialists in orthopedics, neurology, and anesthesia, or other physicians who can demonstrate expertise in the procedure, AND who can provide certification their hospital privileges include the procedure requested under the following conditions:

     (a) Rationale for procedure, treatment plan, and request for authorization must be presented in writing to the department or self-insurer.

     (b) Procedure must be performed in an accredited hospital under radiographic control.

     (c) Not more than four facet injection procedures will be authorized in any one patient.

     (13) The long term prescription of medication under the specific conditions and circumstances in (a) and (b) are considered corrective therapy rather than palliative treatment and approval in advance must be obtained.

     (a) Nonsteroidal anti-inflammatory agents for the treatment of degenerative joint conditions aggravated by occupational injury.

     (b) Anticonvulsive agents for the treatment of seizure disorders caused by trauma.

     (14) Intra-muscular and trigger point injections of steroids and other nonscheduled medications are limited to three injections per patient. The attending doctor must submit justification for an additional three injections if indicated with a maximum of six injections to be authorized for any one patient.

     (15) The department may designate those diagnostic and surgical procedures which can be performed in other than a hospital inpatient setting. Where a worker has a medical condition which necessitates a hospital admission, prior approval of the department or self-insurer must be obtained.



[Statutory Authority: RCW 51.04.020, 51.04.030, and Title 51 RCW. 08-24-047, § 296-20-03001, filed 11/25/08, effective 12/26/08. Statutory Authority: RCW 51.04.020, 51.04.030, 51.32.060, 51.32.072, and 7.68.070. 01-18-041, § 296-20-03001, filed 8/29/01, effective 10/1/01. Statutory Authority: RCW 51.04.020, 51.04.030 and 1993 c 159. 93-16-072, § 296-20-03001, filed 8/1/93, effective 9/1/93. Statutory Authority: RCW 51.04.020(4) and 51.04.030. 90-04-057, § 296-20-03001, filed 2/2/90, effective 3/5/90; 86-20-074 (Order 86-36), § 296-20-03001, filed 10/1/86, effective 11/1/86; 86-06-032 (Order 86-19), § 296-20-03001, filed 2/28/86, effective 4/1/86; 83-16-066 (Order 83-23), § 296-20-03001, filed 8/2/83. Statutory Authority: RCW 51.04.020(4), 51.04.030, and 51.16.120(3). 81-24-041 (Order 81-28), § 296-20-03001, filed 11/30/81, effective 1/1/82; 81-01-100 (Order 80-29), § 296-20-03001, filed 12/23/80, effective 3/1/81. Statutory Authority: RCW 51.04.030 and 51.16.035. 79-12-086 (Order 79-18), § 296-20-03001, filed 11/30/79, effective 1/1/80; Order 76-34, § 296-20-03001, filed 11/24/76, effective 1/1/77.]