Category: Medical Treatment (Page 3 of 36)

My L&I Claim Doctor Says I Need to Lose Weight Before Surgery: Does L&I Cover Weight Loss Treatment?

The Department of Labor and Industries (L&I) covers medical treatment after a work injury or occupational disease. For treatment, L&I accepts certain conditions. Typically, L&I doesn’t cover conditions that do not relate to the workplace injury. However, in some cases, L&I allows temporary treatment of “unrelated conditions”. Specifically, when unrelated conditions prevent recovery from an accepted condition. In fact, L&I allows medical treatment of an unrelated condition as “aid-to-recovery”. Therefore, workers can sometimes receive treatment for obesity or being overweight. L&I considers this an unrelated condition.

L&I weight loss coverage

If you weigh too much, it can hold back your recovery after a work injury. For example, when your injuries involve weight-bearing muscles and joints. Explicit examples include foot injuries, ankles, knees, and hips. Additionally, excess weight can make it challenging to attend rehab treatments. Many times, overweight workers find it difficult to undergo physical therapy. Also, a diagnosis of obesity can delay surgery. This is until weight drops to appropriate levels. Hence, if obesity is a roadblock to recovery, then L&I may cover weight loss treatment.

Criteria for weight loss treatment

A worker must meet certain criteria for L&I to allow weight loss treatment. These criteria include:

1) The worker is “severely obese” with BMI of 35 or more.

2) Obesity is the main barrier to recovery. It’s preventing the worker from making progress on their L&I claim accepted conditions.

3) Weight loss is necessary to allow further treatment, surgery, physical rehabilitation, or returning to work.

How to get L&I pre-authorization for weight loss treatment

L&I requires several steps to pursue weight treatment coverage. First, the worker must request weight loss treatment. Here, L&I must pre-authorize the treatment. Otherwise, L&I will not pay for treatment expenses. To receive pre-authorization, your L&I doctor or attending provider needs to:

Notify L&I or the self-insured employer of the worker’s weight and level of function before the injury. Also, your provider must explain how your weight impacts treatment and recovery.
Describe the medical need for L&I obesity treatment. This includes tests, consultations, or diagnostic studies.
If appropriate, your L&I doctor can request nutrition counseling. A Certified Dietician or Certified Registered Dietician Nutritionist are available.

Unfortunately, L&I won’t approve many popular weight loss methods. Specifically, L&I regularly denies coverage of:

Weight loss surgery, drugs, or medication.
Certain programs or special foods that include meals, supplements, and vitamins.
Cookbooks and educational materials.
Exercise programs and exercise equipment.
Food scales and bathroom scales.

Developing a weight loss treatment plan

Next, L&I requires a plan before they can grant the pre-authorization. In state-funded claims, the L&I claim manager will draft a treatment authorization letter. This letter documents the terms of the plan. Work injury claimants must sign the authorization letter. This way, everyone agrees on the terms of the weight loss plan from the start. Therefore, work injury claimants and their providers must develop a treatment plan and specify:

a) How much weight the worker must lose.

b) Time estimate to complete the weight loss process.

c) The diet and exercise plan or the weight loss plan and methods.

d) The medical provider’s plan for monitoring progress.

e) Plans for documenting weekly weigh-ins.

f) Counseling and education from trained staff as appropriate.

Keeping the L&I authorization for weight loss active

L&I authorizes weight loss treatment in 90-day increments. However, work injury claimants must follow additional requirements to keep the authorization active. These requirements include:

i) Losing at least 5 pounds every 6 weeks.

ii) Attending weekly treatment sessions.

iii) Complying with the treatment plan.

iv) Checking in with the attending provider at least every 30 days.

v) Having the program coordinator sign a weekly weigh-in sheet.

vi) Sending the L&I claims manager the weekly weigh-in sheets.

It’s very important for the attending provider to see the worker every 30 days (or less). Also, the provider must notify the L&I claims manager if:

1) The work injury claimant reaches the weight goal.

2) Weight is no longer a barrier to treatment.

3) If the worker isn’t meeting their weight loss goals.

4) The work injury claimant isn’t cooperating with the treatment plan.

When will my L&I weight loss coverage end?

L&I coverage for weight loss treatment can end. One reasons for ending the coverage is when the work injury claimant reaches the weight goal. A second reason is if the worker’s obesity no longer impedes their recovery. Furthermore, another scenario is when the worker fails to drop the 5-pound minimum requirement over 6 weeks. Finally, L&I can end the treatment authorization if the worker isn’t cooperating with the plan.

Personally, I’ve seen good success with L&I weight loss treatments. Yet, the treatment is very bare-bones and basic. L&I uses mainstream programs, such as Weight Watchers or Noom. However, most plans come down to food modifications and calories deficits.

Concerns for workers receiving weight loss treatment

Due to work injuries, workers rarely take part in exercise programs. Although, walking exercises can be a successful and an integral part of L&I weight loss plans. Also, carefully designed strength training can be very beneficial.

In reality, the public nature of this L&I program can be frustrating to workers. Weight loss is often a very personal experience. Therefore, it can get extremely unpleasant having so many people monitoring your weight loss progress. Weekly weigh-ins can be stressful and demoralizing. Particularly, if the worker is having trouble meeting the mandatory weight loss goals.

Summary and conclusions

That said, L&I coverage for weight loss treatment is a huge benefit. Without it, excess weight can hinder recovery and stall the L&I claim indefinitely. Even worse, it can result in suspension of L&I benefits. In conclusion, there are some issues with these weight loss programs. However, they’re still an incredible benefit within the L&I claim process.

The L&I Claim SIMP Program for Chronic Pain Management

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Are you familiar with the SIMP program? SIMP is an abbreviation for Structured Intensive Multidisciplinary Program. More simply, it’s a chronic pain management program. L&I regularly refers work injury claimants to SIMP during L&I claims. In fact, L&I recommends SIMP for chronic pain when workers don’t respond to conservative care.

What is the SIMP program in L&I claims?

SIMP can be helpful when chronic pain interferes with your ability to work. Furthermore, SIMP is useful when work injury claimants develop dependency on pain medication. However, the program is a somewhat complex and expensive way to treat chronic pain.

The SIMP program is “structured”. That’s because workers receive care in a consistent manner. The care is regular and steady. It has a schedule for modules of assessment. In addition, it includes education, treatment, and follow up evaluations. During the program, caregivers custom-tailor plans to address specific treatment needs for workers.

Key parts of the L&I claim SIMP program for chronic pain

SIMP is also “intensive” because it requires 6-8 hours of daily treatment. The routine continues 5 days a week for up to 4 weeks. The program is also “multidisciplinary”: A team of providers with different yet complementary expertise provide the care. Moreover, providers address pain management in multiple ways. That includes traditional medicine, psychology, physical therapy, and occupational therapy.

Sometimes, the program also includes vocational services and nursing services. Finally, the “program” portion focuses on outcomes. To get there, the program offers coordination and goal-oriented processes. In fact, caregivers regularly measure and document the workers’ progress. Consequently, failure to make progress can result in discharge from the program.

Phases in the SIMP pain management program

If L&I approves a SIMP program, then 3 essential phases follow. The first phase is evaluation. The second phase is treatment. Then, the third is the follow up. Usually, Evaluation is a lengthy process. Program providers conduct a history review and physical exams. They evaluate the likelihood that the work injury claimant will benefit from the program. Plus, they develop a treatment plan during the evaluation. Upon completion, SIMP caregivers submit a report with their findings and recommendations.

After L&I approves the program, the work injury claimant enters the treatment phase. Treatment comprises several important components, which include:

Exercises
Cognitive behavioral therapy
Coordination of services
Education and skill development
Pain and function tracking
Ongoing assessment of unrelated conditions
Doing real or simulated work or daily functional tasks
Establishing return to work goals
Developing a discharge care plan.

When the plan completes, providers provide workers with a discharge report.

Finally, the Follow Up can last up to 6 months after treatment concludes. The goal of the follow-up phase is to reinforce pain management gains. On top, the follow-up supports return to work goals. Additionally, it helps identify setbacks or issues that require intervention.

Takeaways and conclusions

Work injury claimants must give good faith efforts to comply with SIMP treatment plans. After all, in theory, SIMP is ideal for treating complex chronic pain in L&I claims. However, there are ongoing debates as to whether such programs deliver on their promise.

Personally, as an attorney representing injured workers that regularly participate in SIMP, I see too few results. From my perspective, optimal outcomes on paper don’t match reality. I would like to see more attention and legitimacy to how workers feel about their own progress and symptoms. That said, SIMP is one of the only L&I-approved treatments for pain. That’s because pain is subjective. For that, I am grateful even if I don’t always agree with SIMP outcomes.

L&I Claim Reimbursement for Out-of-Pocket Expenses: Will They Pay Me Back?

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Can work injury claimants pay out-of-pocket and get reimbursed later? For example, say I have an L&I claim. I need medication, massages, and braces. I also need therapeutic furniture, equipment, and medical procedures. So, can I just go ahead and pay? And then ask for reimbursement later? Surprisingly, in general the answer is – No!

Can I get reimbursed for L&I claim out-of-pocket expenses?

Interestingly, it’s very unlikely to get reimbursed from L&I for these kinds of expenses. The reason is coverage. While frustrating, you need to wait for L&I to make a coverage decision. That way, you can be sure that they’ll cover expenses. Don’t pay for services yourself. Moreover, if you decide to pay out-of-pocket, don’t plan on reimbursement.

However, L&I does reimburse for some limited out-of-pocket expenses. But there are only a few expenses that qualify. Usually, pre-authorization is required. Simply put, NEVER assume that L&I will reimburse you.

Will L&I reimburse me for any expenses?

The Department of Labor and Industries (L&I) will reimburse work injury claimants for certain expense. In fact, there are 2 categories for which they’ll pay you back. One is Travel. The other is Property. L&I will reimburse you if you travel for treatment, However, that’s only if you meet the following 2 conditions:

1) The treatment provider is more than 15 miles away from your home address; and

2) There are no other providers that can treat your condition within 15 miles.

Also, L&I assumes your home address is the address in your L&I claim file.

Meeting the criteria above is not enough. If you want a reimbursement, you need your claim manager to pre-authorize it. In practice, you need to tell your claim manager that you meet the 2 conditions. Then, ask them for pre-authorization. After that, the claim manager issues a letter pre-authorizing the travel reimbursement. You must have this letter before going to your appointment.

L&I reimbursement for travel and property expenses

If you have pre-authorization, then you must fill out and submit a Travel Reimbursement Request. On top, you must submit a copy of all expense receipts. If you meet the criteria and have pre-authorization, you’ll get reimbursement for parking over $10, tolls, and other travel expenses.

For property, L&I provides reimbursement for a limited number of personal items. For example, property you lost or that was damaged because of a workplace injury. These items include prescription, eye glasses or contacts, and clothing. In addition, it includes boots or shoes, and personal protective equipment.

Per L&I, for reimbursement, you need to complete and submit a Statement for Miscellaneous Services. The form itself makes it seem like there are plenty of things that qualify for reimbursement. Don’t be a fool! Regardless of what the form implies, work injury claimants rarely get payments for anything beyond the travel and property mentioned above.

Your L&I claim, your expenses

In short, only limited travel and personal property is eligible for reimbursement. It’s better to not count of it. Whenever possible, wait for L&I to make a coverage decision. Finally, if you think you qualify for travel reimbursement, then make sure you get pre-authorization first.