Tara Reck, Managing L&I Attorney at Reck Law PLLC - Workers' Compensation Attorneys

Category: Treatment Benefit (Page 1 of 2)

How L&I Makes Medical Treatment Decisions in Washington State

The Department of Labor and Industries (L&I) maintains a set of Medical Aid Rules and accompanying Fee Schedules. Many workers compensation professionals refer to these as “the MARFS”. Typically, the Department updates the L&I medical treatment rules annually in July. The medical aid rules and fee schedules are very important. Many work injury claimants can use them to get answers regarding medical treatment under their L&I claim. The guidelines can even provide answers for certain medical conditions relating to your workplace injury and your claim.


L&I medical aid rules and fee schedules

Under the Industrial Insurance Act (Title 51 of the Revised Code of Washington), L&I is responsible for supervising and providing prompt and efficient treatment to workers injured during their employment. Namely, this treatment must be “at the least cost consistent with promptness and efficiency”. Managing medical treatments for many work injury claimants is complex. Even for large government agencies. To help, L&I created a framework to define the scope and rules around medical treatment. The medical treatment framework, known as Medical Aid Rules and Fee Schedules, is under Chapter 296-20 of the Washington Administrative Code (WAC). L&I uses this framework for claim administration. The framework defines the medical services that L&I and self-insured employer companies can purchase. Additionally, the framework sets the fees they can spend for medical services. Furthermore, it dictates the decision-making process for medical treatment under an L&I claim.


How L&I makes medical treatment decisions

The medical aid rules in WAC 296-20 contain much more information beyond treatment codes and fee structures. In fact, the medical aid rules explain much of L&I’s decision making when it comes to treatment authorizations. For example, the medical aid rules describe the function and role of the chiropractic and medical advisory committees. These committees advise L&I regarding coverage, decisions, treatment guidelines, treatment authorization criteria and the like. The guidelines also contain information about many important topics, including:


In short, the medical treatment guidelines can help work injury claimant and providers alike. That is, they can help understand how L&I and self-insurers make treatment decisions. Even further, they outline the kinds of treatment that L&I and self-insured employers allow.


What are the medical fee schedules?

The L&I fee schedules explain how much money L&I can spend on every medical service. It explicitly dictates the amount of money that L&I pays for each specific medical procedure. The fee schedules are typically used by medical providers and medical administrators. As before, the L&I fee schedules take effect annually each July. The most recent fee schedules for July is available on the L&I website. The website also provides the fee schedules for previous years.


Additionally, L&I has several tools to assist in understanding the fee schedules. Moreover, there are resources on how to appropriately submit bills for services. For example, L&I publishes a “Professional Services Fee Schedule”, which is a spreadsheet of the complete fee schedule (with a few exceptions). Also, L&I provides a “Code Lookup Tool”. These tools are available on the L&I Website. Finally, L&I publishes a guide called Payment Policies for Healthcare Services. L&I provides these for injured workers and crime victims. This payment policy manual is full of detailed information.


What are the L&I medical treatment guidelines?

L&I also has a number of Treatment Guidelines that more explicitly define the kinds of treatment that may be authorized for specific diagnoses and conditions.  Specifically, these treatment guidelines cover:


The treatment guidelines may cover your conditions and diagnosis. Therefore, you should carefully read and understand the treatment guidelines that apply to you. Most importantly, the guidelines provide a clear picture of what treatments L&I will and will not allow. Also, they contain information about treatment options. For example, they outline the order that patients must follow to carry out certain treatments. Finally, these guidelines provide references to medical studies and literature.


How to appeal L&I medical decisions

It’s very unlikely that a claims manager for L&I or a self-insured employer will allow treatment inconsistent with the treatment guidelines. However, it’s important to note that, in most cases, the medical treatment guidelines are not legally binding. For example, say that L&I denies your specific treatment recommendation because it’s not in the treatment guidelines. Still, work injury claimants can successfully appeal the decision. In turn, the appeal would go to the Board of Industrial Insurance Appeals (Board). There, the Board will make an independent determination.


How does the Board of Appeals make a treatment decision? The Board of Appeals decides based on whether the proposed treatment is “necessary and proper”. By law, work injury claimants must receive proper and necessary health care services. Specifically, the law entitles the worker to a diagnosis and treatment of conditions. Of course, these conditions must be causally related to the workplace injury or occupational disease.


Important terms in the L&I medical treatment guidelines

In general, proper and necessary services may be either curative or rehabilitative. The term “Curative” means treatment to produce permanent changes. These changes hope to eliminate or lessen the clinical effects of the condition. Then, “Rehabilitative” treatment aims for workers to regain functional activity on a long-term basis.


Most importantly, the law entitles work injury claimants to proper and necessary health care. That is, until they reach and maintain maximum medical improvement (MMI). A worker is at maximum medical improvement when doctors don’t expect their condition to improve.


Work injury claimants should review the medical guidelines

Under the Industrial Insurance Act, L&I must carefully manage medical treatment decisions. On top, L&I must carefully manage fees for medical services. Too often, L&I and self-insured treatment decisions seem slow, arbitrary, and unfair. This is one reason why I recommend that work injury claimants review and understand the medical guidelines. It’ll help you cut through the mystery. Also, reviewing treatment guidelines can help you advocate for yourself in medical appointments.


The guidelines contain many useful facts. For instance, workers can get a better sense of how many physical therapy sessions L&I or the self-insurer will authorize. Furthermore, workers can identify which upcoming treatments or appointments require L&I pre-authorization. While these are only a few examples, I urge workers to take full advantage of all the information available in the guidelines.


Aggravation of Conditions in L&I Claims: A Simple Guide for Workers

In L&I claims, you often hear the term “aggravation of conditions” or “aggravated conditions”. Your L&I doctor or claim manager may mention “aggravation of pre-existing conditions“. Sometimes, aggravation refers to other claim-related conditions. In short, the term “aggravation” can be very confusing in workers’ compensation claims. The purpose of this article is to help work injury claimants clear the confusion.


What is aggravation of conditions in an L&I claim?

Aggravation of condition is when a medical or mental condition gets worse. For workers, there are 2 important scenarios. These 2 scenarios do not relate to one another. They happen in very different parts of your workman’s comp claim. However, it’s important to pay attention and keep track of aggravation of conditions in both.


Aggravation of pre-existing conditions after a work injury (scenario I)

Say that you suffer an injury on the job. In addition, say that you have some pre-existing conditions. For example, your pre-existing condition can be from another injury or from birth. In workers’ compensation, it’s important to consider if your new work injury triggers symptoms for pre-existing conditions. If it does, we refer to it as aggravation of pre-existing condition.


Aggravation of condition after your L&I claim closed (scenario II)

Here, let’s assume you suffered a workplace injury a while ago. You opened an L&I claim. After that, you received treatment and benefits. Eventually, your L&I claim closed. After some time, there’s aggravation of conditions that relate to your L&I claim (which is already closed). We call this scenario aggravation of claim-related conditions.


New work injury and aggravation of pre-existing condition

If you have pre-existing conditions prior to the work injury, it’s important to track and monitor them. Many times, a workplace injury “lights up” these conditions. Then, whenever this happens, the Department of Labor and Industries (L&I) must decide about coverage. Here, L&I has to determine if they need to provide treatment for the aggravated pre-existing condition. For that, L&I relies on 2 components. The first is proximate cause. The other is lighting up or aggravation.


Proximate cause and pre-existing conditions

As before, say you have a workers’ comp claim for a work injury. Moreover, one of your pre-existing conditions requires treatment. If you can show proximate cause, then L&I must cover your aggravated pre-existing condition. For us, legal professionals, the term “proximate cause” has a specific legal definition. In short, it means you must meet 2 criteria to prove proximate cause.


First, you must show how the work injury caused the aggravation. For that, you have to demonstrate the sequence of events. Then, you must also show that without the work injury, there wouldn’t be aggravation of pre-existing conditions. Also, remember, there can be more than one proximate cause. Yet, for L&I to provide medical coverage, it’s enough to show that the work injury was one proximate cause. It doesn’t have to be the only one.


Lighting up and aggravated pre-existing conditions

A pre-existing condition can be asymptomatic. Meaning, there were no symptoms or disability before the industrial injury. Then, a work injury happens. In turn, the work injury lights up or activates a pre-existing condition. If that’s the case, the worker is eligible for treatment and benefits for their full disability. That includes the aggravated pre-existing conditions.


Sometimes, workers with pre-existing disabilities have a greater need for treatment than other workers. That doesn’t matter. L&I must cover all these conditions and disabilities. Even when they require more attention.

On occasion, a pre-existing condition is symptomatic. For example, if there’s a pre-existing disability before a new work injury. Here, it’s important to check if the new injury aggravated the pre-existing condition. In other words, if it made it worse. If so, then L&I needs to cover the condition under the claim. However, there’s one exception. L&I will not cover the condition if the natural progress of the condition made it worse. This can get very tricky. As always, if you’re not sure what to do, call a workers’ compensation attorney.


Aggravation of pre-existing degenerative conditions

Often, we see aggravation of pre-existing conditions with so-called “degenerative” characteristics. These tend to impact the spine, knees and shoulders. In short, the human body ages. It wears out and degenerates as we get older. In the process, some people experience symptoms. Others don’t.


The following are some examples of degenerative conditions:

1) Degenerative disc disease of the spine

2) Shoulder tears due to aging

3) Degenerative meniscus tears

4) Arthritis in the back, shoulders and knees.


In general, a workplace injury isn’t the originating cause of degenerative conditions. However, it can make them become symptomatic. Also, it can accelerate them or make them worse. Consequently, under the law, L&I cannot reject the degenerative condition. In fact, L&I must cover it under the claim.


Aggravation of conditions and reopening an L&I claim

For workers, the second important scenario is aggravation of claim conditions. If your L&I claim closed, you can reopen it due to aggravation of claim-related conditions. More specifically, it’s very important to reopen the claim when aggravation of conditions results in:

1) Permanent disability (which can lead to L&I pension benefits)

2) Increase in permanent partial disability (or PPD)

3) Need for treatment.


Objective medical findings to reopen an L&I claim

You can file an application to reopen your L&I claim. When L&I evaluates the application, they will look at the following criteria. To reopen the claim due to aggravation of conditions, you must show 3 things:

a) That the aggravation resulted in one of (1), (2) or (3) above.

b) The work injury was a proximate cause for the aggravation.

c) That the aggravation occurred between the terminal dates.


An explanation of terminal dates

Upon reopening, L&I looks at two terminal dates. T1 is the first terminal date. That’s the most recent date when L&I decided to close your claim. Or, it’s the most recent date when L&I decided to keep your claim closed. Then, the second terminal date is T2. That’s when you apply to reopen the claim. How does L&I use these dates? It’s complicated. Let’s look at an example.


Say that Jane Doe suffers an injury at work. Her work accident caused lumbar disc herniation. In addition, let’s assume that she received treatment. Her claim closed in January 2018. After that, Ms. Doe tried to reopen her claim in January 2019. Back then, L&I decided to not reopen the claim. Furthermore, Ms. Doe didn’t protest or appeal the decision. Fast forward, let’s assume that Ms. Doe filed a new reopening application in January 2023. Hence, the first terminal date T1 is January 2019. That’s when L&I decided to keep her claim closed. Then, the second terminal date T2 is January 2023.


Reopening your L&I claim based on aggravation of conditions

To continue, let’s further assume Ms. Doe took an MRI in January 2018. The MRI showed 1 millimeter disc herniation. Later, she had another MRI in January 2019. It showed 1 millimeter disc herniation in the same spot. Finally, another MRI in January 2023 showed 3 millimeter disc herniation. All in the same exact location.


For reopening, L&I will look at all the events between T1 and T2. Clearly, the disc herniation worsened between January 2019 and January 2023. This falls under aggravation of claim-related conditions. So, there’s sufficient objective medical evidence. However, Ms. Doe must also show that the disc deterioration didn’t happen because of natural progression. For that, she must obtain a medical opinion that the work injury is one cause for the aggravation.



This example illustrates the process of reopening a claim after aggravation. Even simple cases can require highly technical and in-depth analysis. Therefore, many medical providers don’t even attempt or advise patients on reopening. They assume L&I will deny reopening. I certainly understand their frustration and hesitation.


However, it’s important for medical providers to know that reopening is possible. An effective partnership with an experienced workers compensation attorney is imperative. This can make the process much smoother.

In summary, aggravation of condition comes up a lot in L&I claims. The term can describe one of two very different scenarios. One involves aggravated pre-existing conditions. The second scenario involves re-opening a claim because of aggravation. While different, it’s important for workers to understand aggravation of conditions and pursue their rights under the law.


L&I Pain Medication and Coverage After a Surgery: What Should I Expect?

I get lots of questions from work injury claimants. Many have concerns regarding L&I medical coverage. This is understandable. It sometimes feels like a mystery. After all, it’s difficult to predict if your L&I claim is going to cover certain treatments. However, I think it’s particularly interesting that most L&I coverage questions come up before and after a surgery.


L&I and pain medication

Usually, L&I authorizes opioid pain medication in the acute phase of an LNI claim. In general, the acute phase comprises the first 6 weeks following the work injury. However, L&I can discontinue opioids if there’s no meaningful recovery progress. On top, they will stop opioid treatment if there’s an adverse reaction or if the patient has substance abuse issues.


Pain medication under an L&I claim after a surgery

Pain management is an important topic for many work injury claimants. Most people want to ensure they won’t suffer from pain following a surgery. Generally, LNI authorizes post-surgical treatment whenever there’s a recommendation from the treating surgeon. Normally, this includes post-surgical checkups and rehabilitative treatment. For example, they cover physical therapy and pain management.


For surgeries, L&I has additional rules. In fact, L&I can authorize opioid pain relievers when it’s consistent with Washington State guidelines. The rule-book containing the guidelines is available here. It’s worth noting that many parties participated in writing these guidelines. They include the Washington State Agency Medical Directors’ Group (AMDG) and expert advisory panels. Other participants are practicing providers, public stakeholders, and senior Washington State officials.


L&I and pain management

In short, the rule-book doesn’t prohibit opioids. With care, and responsibly, it says that opioids can be effective and appropriate in the surgical and post-surgical setting. Therefore, they encourage to prescribe the least invasive and lowest dose regimen to minimize pain.


L&I’s goal is to minimize any negative side effects for the injured worker. This goal is reflective in the opioid prescription recommendations across all surgery phases, i.e., before, during, and after the medical operation. In addition to ensuring the lowest possible dosage to address pain, the guidelines also require proper planning, patient education, monitoring, and follow ups.



In summary, L&I recognizes opioids as a reasonable method for controlling pain.  Both acutely and after surgical procedures. Therefore, L&I does authorize the use of opioids. However, L&I requires doctors and work injury claimants to follow Washington State guidelines and recommendations.


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