The Department of Labor and Industries (L&I) recently collaborated with the Industrial Insurance Medical Advisory Committee and the Lumbar Surgery Subcommittee. Together, they developed a new guideline for low back surgery. Consequently, medical providers that treat work injury claimants for low back conditions need to follow new rules starting October 3, 2021.
L&I claim back injury treatment authorization
Under the guideline, the following procedures will not be authorized under any circumstances:
- Artificial disc replacement
- Sacroiliac joint fusion
- Bone morphogenic protein-7 in lumbar spine fusions
- Vertebroplasty, kyphoplasty, or sacroplasty
- Percutaneous discectomy
- Staggered lumbar fusion procedures
- Interspinous process devices
However, if a work injury claimant meets certain criteria, the following procedures may be covered:
- Lumbar decompressions including laminectomy, discectomy, microdiscectomy, and foraminotomy
- Lumbar fusion
- Bone morphogenic protein-2 in lumbar spine fusions.
Avoiding treatment denial in your L&I claim
Many work injury victims are treated for back injury under their workers’ compensation claim in Washington State. Under your L&I claim, you can check whether your claim administrator should authorize certain treatments. In fact, you can check the guideline and associated criteria on the L&I website. You must make sure that you meet the relevant criteria. If not, Comagine will automatically recommend to deny your treatment.
Sometimes, there are circumstances when providers feel that treatment is appropriate. This is true even if you don’t satisfy the authorization criteria. If that’s your case, then you have several options. First, the recommending provider can have a peer-to-peer review with Comagine. After that, the review might result in treatment authorization. Alternatively, you can appeal treatment denial to the Board of Industrial Insurance Appeals (BIIA).
Appealing L&I claim treatment denial
The BIIA follows legal standards when it reviews treatment authorization appeals. Under the law, treatment should be authorized if it’s proper and necessary. The term “proper and necessary” includes services to diagnose and treat any condition caused by an injury or occupational disease. Furthermore, treatments can also be curative or rehabilitative. Here, curative refers to treatment that produces permanent changes. For example, to eliminate or lessen the clinical effects of a condition. On the other hand, rehabilitative means treatment that helps regain functional activity on a long-term basis.
When appealing treatment authorization, BIIA follows legal definitions to determine if treatment is necessary and proper. Therefore, L&I treatment guidelines have little relevance to the BIIA analysis. Still, it’s unlikely that the BIIA will find new or experimental treatments necessary and proper in the workers’ compensation setting.