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February 04, 2015: Iowa Case Law: The words “arising out
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February  02, 2015: Delaware Workers' Compensation Health
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Schedule").
February 02, 2015: Florida Workers’ Compensation
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2015 Book on Authorization, Utilization Review With 1000 IMR Decisions to Show Why
Treatment is not Being Authorized. Not only did the formalities of the WCAB and the IBR
process change but also the detail requirements in the request for authorization and to get UR
reversal by IMRs. A missed word and a left out explanation, a lack of documents, changes if the
treatment is authorized or if reversed and certified by IMR
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8 WEEK 24 LESSON COURSE  IN WORK COMP TREATMENT AND
COLLECTIONS for $325.00 (INDIVIDUAL OR ENTIRE STAFF)
8 WEEK 24 LESSON COURSE  IN WORK COMP
TREATMENT AND COLLECTIONS for $325.00
(INDIVIDUAL OR ENTIRE STAFF)
Or will come to your location for 4 hour for
same fee as course,  for  lecture and
organizing  you collection and treatment
disputes
Getting Treatment Authorized: Guidelines / Common errors element What Must Be shown  In Medical Reports -As Required BY The IMRs to Get Services Treatment Authorized
LUMBAR SPINE POSTERIOR INTERBODY
FUSION = Guidelines = Elements Required in
Documentation =Common Errors= Authorized
URINE DRUG SCREEN    = Guidelines = Elements Required in
Documentation =Common Errors= Authorized
ONDANSETRON ODT TABLETS 8 MG #60
ONE TUBE OF MEDROX PAIN RELIEF OINTMENT
OPANA
ORPHENADRINE
ORTHOVISC
OXYCONTIN
OXYCONTIN  AND 2) HYDROMOPHONE
PANTOPRAZOLE
PERCOCET
PRILOSEC
PROBIOTICS
PROTONIX
RELPAX
REPLAX
RESTORIL
SENAKOT, GABAPENTIN AND PRILOSEC
SENTRA
SODIUM
SOMA
SYNAPRYN
SYNOVACIN
SYNVISC ONE INJECTION
TABRADOL 1
TEROCIN PAIN PATCH BOX
THERAMINE
TIZANIDINE
TOPIRAMATE
TORADOL
TRAZADONE
TRAZODONE/DESYREL
TYLENOL NO
TYLENOL NO. 3
ULTIMATE SCAR CREAM
ULTRAM
VALIUM
VASCUTHERM
VIAGRA
VICODIN
VISCOSUPPLEMENTATION
VOLAREN GEL
WELLBUTRIN XR
XANAX
ZANAFLEX
ZOFRAN

ZOLPIDEM
ISSUE IN DISPUTE Provider is dissatisfied with denial of
codes 72070 and 72110
ISSUE IN DISPUTE The reimbursement of CPT 17999
for date of service 1/31/2014
ISSUE IN DISPUTE:  Provider is dissatisfied with down
-coding of 99204 to 99203 and reimbursement for
multiple injured workers with separate dates of service.
ISSUE IN DISPUTE : Provider seeking remuneration for
the following medications and
compound medications: NDC 38779187105, NDC
38779273904 , NDC 38779039503,
NDC 38779038803, NDC 38779008202 , NDC
00591367105, NDC 76218121901,
NDC53746011005 and NDC 60505006601 dispensed to
Injured Worker on 05/05/2014
ISSUE IN DISPUTE: Provider seeking remuneration for
97530-59 x 4 Units Physical
Medicine services performed on 02/26/2014–03/05/2014
ISSUE IN DISPUTE :Provider seeking additional
remuneration for WC004 PR4 report
up to 15 pages.Upon second bill review, no additional
payment for WC004 was issued
ISSUE IN DISPUTE: Provider seeking full
remuneration for 82145, 80154,82520
,83925,83925-59,82145-59 Laboratory services
performed on 04/02/2014
ISSUE IN DISPUTE: Provider is dissatisfied with
reimbursement of DRG 454, Inpatient
Services.
ISSUE IN DISPUTE: Provide r seeking remuneration for
Lab Services CPT Codes, 82205, 82520, 83840, 83992 ,
83992, 83925, 83925 - 59, 82145 and 82055 (G4034) for
date of service 01/28/2014
6 Month  24 LESSON
COURSE  IN WORK COMP
TREATMENT AND
COLLECTIONS for $325.00
(INDIVIDUAL OR ENTIRE
STAFF)
Or will come to your location for 4 hour for
same fee as course,  for  lecture and
organizing  you collection and treatment
disputes
ISSUE IN DISPUTE  Provider is dissatisfied with
reimbursement of code 72148
ISSUE IN DISPUTE: Provider seeking full remuneration for  99499 Unlisted Evaluation
and Management services representing Functional Restoration Program for service dates
04/07/2014 04/11/2014.
ISSUE IN DISPUTE: Provider questioning Claims Administrator’s re-coding of 99214
Evaluation and Management service provided to Injured Worker on 01/29/214 and $0.00
reimbursement for 99070 -NDC#68453095010 submitted charge.
Medications: Medical Necessity Issues and Treatment Guidelines
AMBIEN = Guidelines = Elements Required in Documentation =Common Errors= Authorized
ANAPROX  = Guidelines = Elements Required in Documentation =Common Errors= Authorized
ATIVAN = Guidelines = Elements Required in Documentation =Common Errors= Authorized
CAPSAICIN 0.025%, FLURBIPROFEN 20%, TRAMADOL 10%,MENTHOL 2%, CAMPHOR 2%=
Guidelines = Elements Required in Documentation =Common Errors= Authorized
CARAFATE = Guidelines = Elements Required in Documentation =Common Errors= Authorized
CARISOPRODOL = Guidelines = Elements Required in Documentation =Common Errors= Authorized
CELEBREX= Guidelines = Elements Required in Documentation =Common Errors= Authorized
CLONAZEPAM  = Guidelines = Elements Required in Documentation =Common Errors= Authorized
COLACE= Guidelines = Elements Required in Documentation =Common Errors= Authorized
COMPOUND CREAM= Guidelines = Elements Required in Documentation =Common Errors= Authorized
COMPOUND GABAPENTIN POWDER= Guidelines = Elements Required in Documentation =Common
Errors= Authorized
CYCLOBENZAPRINE= Guidelines = Elements Required in Documentation =Common Errors= Authorized
CYMBALTA= Guidelines = Elements Required in Documentation =Common Errors= Authorized
DENDRACIN= Guidelines = Elements Required in Documentation =Common Errors= Authorized
DIAZEPAM (VALIUM)= Guidelines = Elements Required in Documentation =Common Errors= Authorized
DICLOFENAC  = Guidelines = Elements Required in Documentation =Common Errors= Authorized
DICOPANOL (DIPHENHYDRAMINE)= Guidelines = Elements Required in Documentation =Common
Errors= Authorized
DICYCLOMINE HCL 2= Guidelines = Elements Required in Documentation =Common Errors= Authorized
DILAUDID= Guidelines = Elements Required in
Documentation =Common Errors= Authorized
CARDIAC CLEARANCE   = Guidelines = Elements Required
in Documentation =Common Errors= Authorized
CARDIOLOGY CONSULT = Guidelines = Elements
Required in Documentation =Common Errors= Authorized
COGNITIVE BEHAVIOR THERAPY    = Guidelines =
Elements Required in Documentation =Common Errors=
Authorized
CONSULT WITH PAIN MANAGEMENT = Guidelines =
Elements Required in Documentation =Common Errors=
Authorized
CT SCAN = Guidelines = Elements Required in
Documentation =Common Errors= Authorized
DME         H-WAVE UNIT= Guidelines = Elements Required in
Documentation =Common Errors= Authorized
DME TENS        THE REQUEST FOR TENS UNIT
PURCHASE: = Guidelines = Elements Required in
Documentation =Common Errors= Authorized
EKG = Guidelines = Elements Required in Documentation
=Common Errors= Authorized  EKG
ELECTROENCEPHALOGRAPHY (EEG) = Guidelines =
Elements Required in Documentation =Common Errors=
Authorized
ELECTROMYOGRAM    = Guidelines = Elements
Required in Documentation =Common Errors= Authorized
EMG/NCS   = Guidelines = Elements Required in
Documentation =Common Errors= Authorized
EVALUATION FOR FUNCTIONAL RESTORATION     
= Guidelines = Elements Required in Documentation
=Common Errors= Authorized
FUNCTIONAL RESTORATION PROGRAM =
Guidelines = Elements Required in Documentation
=Common Errors= Authorized
EXTRACORPOREAL SHOCK WAVE TREATMENT =
Guidelines = Elements Required in Documentation
=Common Errors= Authorized
GROUP THERAPY = Guidelines = Elements Required in
Documentation =Common Errors= Authorized
HOME HEALTH CARE = Guidelines = Elements Required
in Documentation =Common Errors= Authorized
SLEEP EVALUATION WITH TESTING= Guidelines =
Elements Required in Documentation =Common Errors=
Authorized
INTRATHECAL PUMP = Guidelines = Elements Required in
Documentation =Common Errors= Authorized
MANIPULATION UNDER ANESTHESIA = Guidelines =
Elements Required in Documentation =Common Errors=
Authorized
NCS (NERVE CONDUCTION STUDY) = Guidelines =
Elements Required in Documentation =Common Errors=
Authorized
NEUROLOGICAL CONSULTATION   = Guidelines = Elements
Required in Documentation =Common Errors= Authorized
NEUROSTIMULATION THERAPY = Guidelines = Elements
Required in Documentation =Common Errors= Authorized
REFERRAL TO NEUROSURGEON = Guidelines = Elements
Required in Documentation =Common Errors= Authorized
NUCLEAR STRESS TEST = Guidelines = Elements Required in
Documentation =Common Errors= Authorized
OCCUPATIONAL THERAPY= Guidelines = Elements Required
in Documentation =Common Errors= Authorized
PAIN MANAGEMENT    = Guidelines = Elements Required in
Documentation =Common Errors= Authorized
PHYSICAL THERAPY   = Guidelines = Elements Required in
Documentation =Common Errors= Authorized
PLATELET RICH PLASMA INJECTION  = Guidelines =
Elements Required in Documentation =Common Errors=
Authorized
PNEUMATIC INTERMITTENT COMPRESSION   =
Guidelines = Elements Required in Documentation =Common
Errors= Authorized
INTERMITTENT COMPRESSION DEVICE= Guidelines =
Elements Required in Documentation =Common Errors=
Authorized
PRE-OP TESTING = Guidelines = Elements Required in
Documentation =Common Errors= Authorized
PSYCHE TREATMENT= Guidelines = Elements Required in
Documentation =Common Errors= Authorized
PSYCHIATRIC MEDICATIONS MANAGEMENT   =
Guidelines = Elements Required in Documentation =Common
Errors= Authorized
PSYCHIATRY VISITS   = Guidelines = Elements Required
in Documentation =Common Errors= Authorized
PSYCHOLOGICAL EVALUATION = Guidelines = Elements
Required in Documentation =Common Errors= Authorized
PSYCHOPHARMACOLOGY MANAGEMENT    
= Guidelines = Elements Required in Documentation
=Common Errors= Authorized
PSYCHOTHERAPY      = Guidelines = Elements
Required in Documentation =Common Errors=
Authorized
SKILLED NURSING  = Guidelines = Elements
Required in Documentation =Common Errors=
Authorized
SPINAL SURGICAL CONSULTATION= Guidelines
= Elements Required in Documentation =Common
Errors= Authorized
DEBRIDEMENT OF THE RIGHT SHOULDER =
Guidelines = Elements Required in Documentation
=Common Errors= Authorized
TRIGGER POINT AND TENDER SPOT INJECTIONS =
Guidelines = Elements Required in Documentation =Common
Errors= Authorized
LUMBAR FUSION W/ INSTRUMENTATION, USE
AUTOGRAFT AND/OR ALLOGRAFT:= Guidelines =
Elements Required in Documentation =Common Errors=
Authorized
EPIDURAL STEROID INJECTION = Guidelines = Elements
Required in Documentation =Common Errors= Authorized
SHOULDER OPEN ROTATOR CUFF REPAIR = Guidelines =
Elements Required in Documentation =Common Errors=
Authorized
KNEE ARTHROSCOPY= Guidelines = Elements Required in
Documentation =Common Errors= Authorized
SHOULDER ARTHROSCOPY = Guidelines = Elements
Required in Documentation =Common Errors= Authorized
WORK HARDENING VISITS = Guidelines = Elements
Required in Documentation =Common Errors= Authorized
H-WAVE STIMULATION. = Guidelines = Elements
Required in Documentation =Common Errors= Authorized
DUEXIS= Guidelines = Elements Required in Documentation =Common Errors= Authorized
EFFEXOR= Guidelines = Elements Required in Documentation =Common Errors= Authorized
FENTANYL= Guidelines = Elements Required in Documentation =Common Errors= Authorized
FEXMID = Guidelines = Elements Required in Documentation =Common Errors= Authorized
FLECTOR= Guidelines = Elements Required in Documentation =Common Errors= Authorized
FLEXIRIL= Guidelines = Elements Required in Documentation =Common Errors= Authorized
FLURBIPROFEN CREAM,= Guidelines = Elements Required in Documentation =Common Errors= Authorized
FLURIFLEX (FLURBIPROFEN/CYCLOBENZAPRINE 15/10 %) CREAM 1= Guidelines = Elements
Required in Documentation =Common Errors= Authorized
GABAPENTIN= Guidelines = Elements Required in Documentation =Common Errors= Authorized
HYDROCODONE= Guidelines = Elements Required in Documentation =Common Errors= Authorized
DME Varies  = Guidelines = Elements Required in
Documentation =Common Errors= Authorized  EKG
IBUPR= Guidelines = Elements Required in Documentation =Common Errors= Authorized
KETOPROFEN= Guidelines = Elements Required in Documentation =Common Errors= Authorized
KLONOPIN= Guidelines = Elements Required in Documentation =Common Errors= Authorized
LIDOCAINE PAD= Guidelines = Elements Required in Documentation =Common Errors= Authorized
LIDODERM PATCH= Guidelines = Elements Required in Documentation =Common Errors= Authorized
LINZESS= Guidelines = Elements Required in Documentation =Common Errors= Authorized
LORTAB ELIXIR= Guidelines = Elements Required in Documentation =Common Errors= Authorized
LYRICA= Guidelines = Elements Required in Documentation =Common Errors= Authorized
MELOXICAM (MOBIC)= Guidelines = Elements Required in Documentation =Common Errors= Authorized
METHODERM OINTMENT= Guidelines = Elements Required in Documentation =Common Errors=
Authorized
MENTHODERM= Guidelines = Elements Required in Documentation =Common Errors= Authorized
MORPHINE SULFATE= Guidelines = Elements Required in Documentation =Common Errors= Authorized
MS CONTIN= Guidelines = Elements Required in Documentation =Common Errors= Authorized
NABUMETONE= Guidelines = Elements Required in Documentation =Common Errors= Authorized
NAPROXEN= Guidelines = Elements Required in Documentation =Common Errors= Authorized
NOCTURNAL OBSTRUCTIVE AIRWAY ORAL APPLIANCE / DECAY OR FRACTURED TEETH=
Guidelines = Elements Required in Documentation =Common Errors= Authorized
NORCO= Guidelines = Elements Required in Documentation =Common Errors= Authorized
NUCYNTA= Guidelines = Elements Required in Documentation =Common Errors= Authorized
OMEPRAZOLE= Guidelines = Elements Required in Documentation =Common Errors= Authorized
ONDANSETRON ODT = Guidelines = Elements Required in Documentation =Common Errors= Authorized
Sample Program Now Uploaded

Treatment / Payment  Guidelines for Acupuncture

Thursday, April 16, 2015

10:50 AM

 

 

Acupuncture is used as an option when pain medication is reduced and not tolerated, it may be used as an adjunct to physical rehabilitation and/or surgical intervention to hasten functional recovery". "Time to produce function improvement: 3-6 treatments. 2) Frequency: 1-3 times per week. 3) Optimum duration: 1-2 months.

 

Acupuncture treatments may be extended if functional improvement is documented". Patient hasn't had prior Acupuncture treatment. Per guidelines 3-6 treatments are sufficient for initial course of Acupuncture. Additional visits may be rendered if the patient has documented objective functional improvement. MTUS-Definition 9792.20 (f) "Functional improvement means either a clinically significant improvement in activities of daily living or a reduction in work restrictions as measured during the history and physical exam. Per guidelines and review of evidence

 

Acupuncture is a useful tool that can be used to reduce pain, reduce inflammation, increase blood flow, increase range of motion, and also decreases side effects of medications. The time to produce functional improvement is 3-6 sessions and this patient was allowed 6 sessions.

 

Standard:

  • 3-6 treatments.
  • 2) Frequency: 1-3 times per week.
  • 3) Optimum duration: 1-2 months.
  • Acupuncture treatments may be extended if functional improvement is documented".

 

Additional Beyond Trial Period

 

MTUS-Definition 9792.20 (f) "Functional improvement means either a clinically significant improvement in activities of daily living or a reduction in work restrictions as measured during the history and physical exam. Per guidelines and review of evidence

 

Common Errors:

  • Wrong Frequency
  • Failure to show Functional Improvement
  • documentation of duration and frequency of this intervention for the patient's pain complaints were not evidenced.
  • a lack of documentation indicating efficacy of treatment with acupuncture interventions for the patient's lumbar spine pain complaints.
  • no indication that the patient obtained any significant objective benefits (like decrease of pain (Visual Analog Scale), increased endurance, increased body mechanics and ability to perform ADL (activities of daily living), increased ability to perform job-related duties, reduction of pain medication, improved sleep or reduced pain behaviors).

 

Guidelines:

 

MTUS Acupuncture Treatment Guidelines

 

 

 

Payments issues:

 

 

ANALYSIS AND FINDING

Based on review of the case file the following is noted:

•ISSUE IN DISPUTE:Provider is dissatisfied with denial of one (1) unit of 97750.

•Claims Administrator denied 97750 indicating on the Explanation of Review “Reimbursement for physical medicine procedures, modalities, including chiropractic manipulation and acupuncture codes are limited to 60 minutes.”

•When billing for physical medicine modality, procedure, or acupuncture codes, no

•more than 60 minutes on the same visit; Where modalities and procedures are billed: no more than 4 codes total on the same visit

•Provider billed codes 97530 x 3, 97750 x 2 and G0283.

•Both 97530 and 97750 are time based codes each 15 minutes.

•Documentation received included Provider’s treatment notes which documents time for code 97530. Documented time could not be found for code 97750.

•Based on information reviewed, Claims Administrator was correct to deny code 97750.

Therefore, no reimbursement for code 97750 is warranted.

 

ANALYSIS AND FINDING

Based on review of the case file the following is noted:

 

•ISSUE IN DISPUTE: Provider is dissatisfied with denial of code 97140.

 

•Claims Administrator denied code indicating on the Explanation of Review “The billed service falls outside your scope of practice.”

•The Provider is a licensed Acupuncturist. According to the Association of Registered Acupuncturists, an ‘Acupuncturist’ will be defined as someone who offers health care services based on: A. the specific anatomical and physiologic understandings of Traditional Chines Medicine; B. the specific assessment approaches of Traditional Chinese Medicine and; C. the specific therapeutic techniques of Traditional Chinese Medicine.”

 

•Therapies that fall within the scope of practice of the Acupuncturists include, Tuina and Amma (traditional Chinese massage) which the Provider has billed 97140 manual therapy and is part of the licensed Acupuncturist’s scope of practice. •Based on information reviewed, the Claims Administrator was incorrect to deny code 97140. Therefore, reimbursement of code 97140 is warranted

 

ANALYSIS AND FINDING

Based on review of the case file the following is noted:

•ISSUE IN DISPUTE:

Provider seeking remuneration for 97530-59 x 4 Units Physical Medicine services performed on 02/26/2014 –

03/05/2014.

The Claims Administrator denied the services indicating: “Per CCI Edits, the value of this procedure is included in the value of the mutually exclusive procedure.”

 

•NCCI edits reveal 97530 is Colum 2 Code when billed with Colum 1 Code, 97140.

 

•Under certain circumstances, the paired codes in question may be unbundled with the use of modifier -59 provided the “two procedures of a code pair edit are performed in different timed intervals even if sequential during the same patient encounter.”

 

•Documentation of Patient visit includes Exercise Log noting duration of each exercise.

 

•Documentation regarding start and end times for 97530        Therapeutic Exercise and 97140 Manual Exercise, were not noted. Times entries for each exercise did not clarify whether the sessions were performed separately, simultaneously, or sequentially.

TWELVE (12) SESSIONS OF ACUPUNCTURE: Overturned

 

Claims Administrator guideline: Decision based on MTUS Acupuncture Treatment  Guidelines.

 

MAXIMUS guideline: Decision based on MTUS Acupuncture Treatment Guidelines.

 

Decision rationale:

 

Per Acupuncture Medical Treatment Guidelines p9, "(c) Frequency and duration of acupuncture or acupuncture with electrical stimulation may be performed as follows: (1) Time to produce functional improvement: 3 to 6 treatments. (2) Frequency: 1 to 3 times per week. (3) Optimum duration: 1 to 2 months. (d) Acupuncture treatments may be extended if functional improvement is documented as defined in Section 9792.20" The MTUS definition of functional improvement is as follows: ""Functional improvement" means either a clinically significant improvement in activities of daily living or a reduction in work restrictions as measured during the history and physical exam, performed and documented as part of the

evaluation and management visit billed under the Official Medical Fee Schedule (OMFS) pursuant to sections 9789.10-979.111; and a reduction in the dependency on continued medical treatment." The documentation submitted for review indicates the injured worker has completed 12 sessions of acupuncture with good effect. Per 12/10/13 Utilization Treatment Review Appeal, the injured worker had improvement in walking tolerance and felt more flexible. She was able to stop using the cane for a full week after her acupuncture treatment ended. However, after a week, she woke up with a flare-up of back pain and she could barely stand. As the injured worker has documented functional improvement, and a reduction on the dependence of continued medical treatment, extension of acupuncture treatment is warranted. The request is medically necessary. It should be noted that the UR physician has modified the request and certified three sessions of acupuncture.

 

Pasted from <http://www.dir.ca.gov/dwc/IMR/IMR-Decisions/IMR-Decisions2014/IMR2013_60001-70000/CM13-0063123.pdf>

 

 

CM14-0037954.pdf

ACUPUNCTURE

ACUPUNCTURE WITHOUT STIMULATION 15 MIN

As the patient continued symptomatic despite previous care (chiropractic-physical therapy, oral medication and work modifications, amongst others) an acupuncture trial for pain management would have been reasonable and supported by the MTUS. The current mandated guidelines note that the amount to produce functional improvement is 3 to 6 treatments. Seeing that the PTP requested initially 8 sessions, which is exceeding the number recommended by the guidelines without documenting any extraordinary circumstances, the request is seen as excessive, therefore not supported for medical necessity

MTUS Acupuncture Treatment Guidelines.

UR Denial Upheld

 

CM13-0010109.pdf

Acupuncture

Acupuncture Cervical Spine Bilateral Wrist 2 times a week for 6 weeks 

Patient Stated help relieve pain – however no documentation of objective functional improvements from prior acupuncture

MTUS  ACOEM acupuncture treatment guidelines

UR Denial Up Held

 

CM13-0010144.pdf

Acupuncture

12 Acupuncture Sessions

Decision rationale: The current request is not supported. The clinical documentation submitted for review reports the patient continues to present with lumbar spine pain complaints status post  work related motor vehicle accident sustained in 04/2013. The requesting provider is recommending 12 sessions of acupuncture therapy for the patient's pain complaints ; however, California MTUS Acupuncture Guidelines indicate, "Frequency and duration of acupuncture or acupuncture with E-stim may be performed as follows: time to produce functional improvement, 3 treatments to 6 treatments." The current request is excessive in nature and cannot be modified. Therefore, the request for 12 Acupuncture sessions between 7/31/2013 and 9/14/2013 is neither medically necessary nor appropriate

MTUS Acupuncture Treatment Guidelines

UR Denial Up Held

 

CM13-0010371.pdf

acupuncture

Outpatient acupuncture treatments three (3) times a week for two (2) weeks for the

thoracic region and bilateral shoulders

 

The current mandated guidelines read extension of acupuncture care could be supported for medical necessity "if functional improvement is documented as either a clinically significant improvement in activities of daily living or a reduction in work restrictions and a reduction in the dependency on continued medical treatment." As previously documented, there is no evidence of significant, objective functional improvement (quantifiable response to treatment) obtained with previous care which is essential to establish the reasonableness and necessity of additional acupuncture. There is no indication that the patient obtained any significant objective benefits (like decrease of pain (Visual Analog Scale), increased endurance, increased body mechanics and ability to perform ADL (activities of dailyliving), increased ability to perform job-related duties, reduction of pain medication, improved sleep or reduced pain behaviors). Consequently the request for additional acupuncture is not supported for medical necessity

MTUS Acupuncture Treatment Guidelines.

UR Denial Upheld

 

CM13-0051102.pdf

acupuncture

Six acupuncture visits for the lumbar sacral

Decision rationale:The clinical documentation submitted for review reports the patient continues to present with lumbar spine pain complaints status post a work related fall with injury sustained on 03/30/2013. The provider documents the patient was to continue utilization of acupuncture interventions. However, documentation of duration and frequency of this intervention for the patient's pain complaints were not evidenced. In addition, there was a lack of documentation indicating efficacy of treatment with acupuncture interventions for the patient's lumbar spine pain complaints. The Acupuncture Medical Treatment Guidelines state the time to produce functional improvement is 3 to 6 treatments. The request for six acupuncture visits for the lumbar sacral are is not medically necessary or appropriate.

Decision based on MTUS Acupuncture Treatment Guidelines

Upheld

 

CM14-0000988.pdf

Acupuncture

Acupuncture for Anxiety/Depressive disorder, #12 is not medically necessary and appropriate.

:

 

According to evidenced based guidelines, an initial trial of acupuncture consists of six visits. A request for twelve visits exceeds the recommended number and therefore is not medically necessary. If objective functional improvement is demonstrated, further visits may be certified after the trial. "Functional improvement" means either a clinically significant improvement in activities of daily living or a reduction in work restrictions. Six visits were approved as a trial on 12/2/2013. There is no documentation of completion of the trial or of functional improvement from the trial. Therefore further acupuncture is not medically necessary

Decision based on MTUS Acupuncture Treatment Guidelines.

Upheld

 

CM14-0001311.pdf

Acupuncture

Acupuncture therapy 2 x 4

Decision rationale:Per MTUS-Section 9792.24.1 Acupuncture Medical treatment Guidelines Page 8-9. "Acupuncture is used as an option when pain medication is reduced and not tolerated, it may be used as an adjunct to physical rehabilitation and/or surgical intervention to hasten functional recovery". "Time to produce function improvement: 3-6 treatments. 2) Frequency:1-3 times per week. 3) Optimum duration:1-2 months. Acupuncture treatments may be extended if functional improvement is documented". Patient hasn't had prior Acupuncture treatment. Per guidelines 3-6 treatments are sufficient for initial course of Acupuncture. Additional visits may be rendered if the patient has documented objective functional improvement. MTUS-Definition 9792.20 (f) "Functional improvement means either a clinically significant improvement in activities of daily living or a reduction in work restrictions as measured during the history and physical exam. Per guidelines and review of evidence, 8 Acupuncture visits are not medically necessary

Decision based on MTUS Acupuncture Treatment Guidelines.

Upheld

 

CM14-0001374.pdf

Acupuncture

Acupuncture 2 x week for 6 weeks for left shoulder and neck

Per MTUS-Section 9792.24.1 Acupuncture Medical treatment Guidelines page 8-9. "Acupuncture is used as an option when pain medication is reduced and not tolerated,

it may be used as an adjunct to physical rehabilitation and/or surgical intervention to hasten

functional recovery". "Time to produce function improvement: 3-6 treatments. 2) Frequency: 1-3 times per week. 3) Optimum duration: 1-2 months. Acupuncture treatments may be extended if functional improvement is documented". Patient has had prior acupuncture treatment. There is lack of evidence that prior acupuncture care was of any functional benefit. Acupuncture progress notes were not provided for review. There is no assessment in the provided medical records of functional efficacy with prior acupuncture visits. Additional visits may be rendered if the patient has documented objective functional improvement

. Per MTUS guidelines, Functional improvement means either a clinically significant improvement in activities of daily living or a reduction in work restrictions as measured during the history and physical exam. Per review of evidence and guidelines, 2X6 acupuncture treatments are not medically necessary

MTUS Acupuncture Treatment Guidelines

Upheld

 

CM14-0001710.pdf

Acupuncture

Twelve (12) sessions of acupuncture

for the lumbar spine

The Physician Reviewer's decision rationale: California MTUS Guidelines state acupuncture is used as an option when pain medication is reduced or not tolerated, and may be used as an adjunct to physical rehabilitation and/or surgical intervention to hasten functional

recovery. The time to produce functional improvement includes 3 to 6 treatments. As per the

documentation submitted, the patient has completed a substantial amount of acupuncture

treatment to date. Despite ongoing treatment, the patient continues to report persistent pain.

Satisfactory response to previous acupuncture therapy has not been provided. Additionally, the request for 12 sessions of acupuncture treatment exceeds guideline recommendations. Based on the clinical information received, the request is non-certified.

Decision based on MTUS Acupuncture Treatment Guidelines.

Upheld

 

CM14-0001773.pdf

Acupuncture

Additional 6 Acupuncture visits for Rt Knee

Acupuncture is a useful tool that can be used to reduce pain, reduce inflammation, increase blood flow, increase range of motion, and also decreases side effects of medications. The time to produce functional improvement is 3-6 sessions and this patient was allowed 6 sessions. However, there is no documentation of the functional improvement that the

patient received. This would include an improvement in activities of daily living or a reduction in work restrictions and a reduction in the dependency of continued medical treatment. Without documentation of functional improvement, continued acupuncture treatment cannot be considered medically necessary.

Decision based on MTUS Acupuncture Treatment Guidelines

Upheld

 

CM14-0001813.pdf

Acupuncture

Acupuncture for the right knee times 12

In the case of this injured worker, there is documentation that the employee

has had previous right knee surgery involving a meniscectomy. The employee has tried

conservative management with physical therapy and home exercises. However the MTUS

Guidelines require a trial of six visits of acupuncture with demonstration of functional benefit prior to requesting additional sessions. Therefore the current request for 12 sessions of acupuncture is outside of guidelines and is recommended for noncertification

MTUS Acupuncture Treatment Guidelines.

Upheld

 

CM14-0001844.pdf

Acupuncture

Acupuncture therapy two times a week for four weeks

Decision rationale:As noted in the MTUS Acupuncture Guidelines, the time deemed necessary to produce functional improvement following introduction of acupuncture is three to six treatments. In this case, however, the eight -session course of treatment proposed by the attending provider was in excess of MTUS Guidelines' parameters. Consequently, the request is not medically necessary and appropriate

Decision based on MTUS Acupuncture Treatment Guidelines.

Upheld

 

CM14-0002442.pdf

Acupuncture

EIGHTEEN (18) SESSIONS OF ACUPUNCTURE

The California MTUS Guidelines state acupuncture is used as an option when pain medication is reduced or not tolerated, and may be used as an adjunct to physical

rehabilitation and/or surgical intervention. The time to produce functional improvement includes 3 to 6 treatments. The current request for 18 sessions of acupuncture treatment greatly exceeds Guideline recommendations. Therefore, the request is not medically appropriate. As such, the request for eighteen (18) sessions of acupuncture is non-certified

MTUS Acupuncture Treatment Guidelines.

Upheld

 

CM14-0016990.pdf

ACUPUNCTURE

ACUPUNCTURE TWO (2) TIMES A WEEK FOR SIX (6) WEEKS

The Acupuncture Medical Treatment Guideline states that acupuncture may be extended if there is documentation of functional improvement. Records show that the patient has had acupuncture treatment in the past. The acupuncturist stated that the patient was better and the treatment was tolerated in the chart note dated 2/24/2 013. The patient was the same according to the chart note dated 3/05/2013. The provider noted that acupuncture does not help the patient in the professional referral slip dated 2/24/2014. Based on the lack of functional improvement from acupuncture, the provider's request for additional acupuncture 2 times a week for 6 weeks is not medically necessary.

MTUS Acupuncture Treatment Guidelines

UR Denial Upheld

 

CM14-0029152.pdf

ACUPUNCTURE

12 SESSIONS OF ACUPUNCTURE 2 PER WEEK FOR 6 WEEKS TO THE LUMBAR SPINE

According to evidenced based guidelines, further acupuncture visits after an initial trial are medically necessary based on documented functional improvement. "Functional improvement" means either a clinically significant improvement in activities of daily living or a reduction in work restrictions. The employee has had at least 18 acupuncture visits in the last year. However the provider failed to document functional improvement associated with the acupuncture visits. Instead it appears that acupuncture has had no functional benefit and even has worsening effects over time. Therefore further acupuncture is not medically necessary

MTUS Acupuncture Treatment Guidelines.

UR Denial Upheld

 

CM14-0030226.pdf

ACUPUNCTURE

ACUPUNCTURE, 1 TIME A W

EEK FOR 8` WEEKS:

Acupuncture is used as an option when pain medication is reduced and not tolerated, it may be used as an adjunct to physical rehabilitation and/or surgical intervention to hasten functional recovery". "Time to produce function improvement: 3-6 treatments. 2) Frequency: 1-3 times per week. 3) Optimum duration: 1-2 months. Acupuncture treatments may be extended if functional improvement is documented". Patient hasn't had prior Acupuncture treatment. Per guidelines 3-6 treatments are sufficient for initial course of Acupuncture. Additional visits may be rendered if the patient has documented objective functional improvement. MTUS-Definition 9792.20 (f) "Functional improvement means either a clinically significant improvement in activities of daily living or a reduction in work restrictions as measured during the history and physical exam. Per guidelines and review of evidence, 8 Acupuncture visits are not medically necessary

Non-MTUS Citation Non-MTUS Citation: Acupuncture Medical Treatment Guidelines

UR Denial Upheld

 

 

 

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TENS UNITS AUTHORIZATION AND PAYMENTS 

Thursday, April 16, 2015

7:14 PM

 

 

ANALYSIS AND FINDING

 

Based on review of the case file the following is noted: ·

 

ISSUE IN DISPUTE: Provider is dissatisfied with reimbursement of HCPCS E0730-NU. E0730 –EMS/TENS unit.

·

Effective for services rendered on or after April 1, 2014 , the maximum reasonable fees for Durable Medical Equipment, Prosthetics, Orthotics, Supplies shall not exceed 120% of the applicable California fees set forth in the Medicare calendar year 2014 “Durable

Medical Equipment, Prosthetics/Orthotics, and Supplies (DMEPOS) Fee Schedule” revised for April 2014

 

 

Claims Administrator denied HCPCS E0730 and indicated on the Explanation of Review “Billed rental item has been previously purchased.”

·

Based on review of documentation submitted, Provider states he dispensed the E0730, TENS unit with 2 Pads as a replacement since the previously purchased unit was not properly functioning anymore. Approved authorization dated 4/18/2014 for 1 unit TENS Device by Claims Administrator was also received for this review.

·

Provider states there is a PPO Contract discount of 10% that shall be applied to reimbursement.

 

Pasted from <http://www.dir.ca.gov/dwc/IBR/IBR%20Decisions/IBR%20Decisions%2014-001000%20thru%2014-004999/IBR-14-1011.pdf>

 

MTUS Chronic Pain Medical Treatment Guidelines do not recommend TENS as a primary treatment modality, but support consideration of a one-month home-based TENS trial used as an adjunct to a program of evidence-based functional restoration. Furthermore, criteria for the use of TENS includes pain of at least three months duration, evidence that other appropriate pain modalities have been tried (including medication) and failed, and a documented one-month trial period stating how often the unit was used, as well as outcomes in terms of pain relief and function.

 

 

MTUS Guidelines state transcutaneous electrotherapy is not recommended as a primary treatment modality, but a one month home-based trial may be considered as a non-invasive conservative option. There should be evidence that other appropriate pain modalities have been tried and failed.

 

 

30 DAY RENTAL OF TENS UNIT: Overturned

 

Claims Administrator guideline: Decision based on MTUS Chronic Pain Treatment Guidelines

TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) Page(s): 114-11.

 

MAXIMUS guideline: Decision based on MTUS Chronic Pain Treatment Guidelines TENS,

CHRONIC PAIN Page(s): 114-116.

]

Decision rationale:

According to the 08/17/13 progress report provided by , the patient presents with tendonitis of the hand/wrist/finger, sprain/strain of the elbow/forearm, tendonitis of the shoulder, and carpal tunnel syndrome. The request is for a 30 day rental of a TENS unit. 09/09/13 progress report states that the patient has tried the TENS unit in physical therapy and has benefited from the use of the TENS unit. She has actually benefited from both [TENS unit and H-wave] and according to the patient, she has benefited slight more from the H-wave, but the TENS unit has been effective in reducing her use of medication, particularly anti-inflammatory medication and her need for more aggressive treatment. The request was denied by utilization review letter dated 08/21/13. The rationale stated that the 30 day rental of the TENS

unit was that not supported as a primary treatment modality. Per MTUS guidelines, TENS units

have no proven efficacy in treating chronic pain and are not recommend as a primary treatment

modality, but a one month home based trial may be considered for specific diagnosis of neuropathy, CRPS, spasticity, phantom limb pain, or multiple sclerosis. Since the TENS unit has already provided benefit to the patient, a 30 day rental of the TENS unit should be given.

Recommendation is for authorization.

 

Pasted from <http://www.dir.ca.gov/dwc/IMR/IMR-Decisions/IMR-Decisions2014/IMR2013_20001-30000/CM13-0028659.pdf>

 

 

TENS unit purchase with supplies: Overturned

 

Claims Administrator guideline: The Claims Administrator did not cite any medical evidence for its decision.

 

MAXIMUS guideline: Decision based on MTUS Chronic Pain Treatment Guidelines TENS Page(s): 116.

 

Decision rationale: The Physician Reviewer's decision rationale: As noted on page 116 of the MTUS Chronic Pain Medical Treatment Guidelines, criteria for the purchase of a TENS unit include evidence of a successful one month's trial of the same. In this case, there is seeming evidence of a successful one-month trial of a conventional TENS unit. The applicant uses the TENS unit on a nightly basis. The applicant reports reduction in need for pain medications. The

applicant is now apparently only using one oral analgesic, Celebrex, for pain relief. His pain scores are appropriately reduced. For all of these reasons, it appears that the TENS unit trial has been successful. Purchasing the same is therefore endorsed. Accordingly, the original utilization review decision is overturned. The request is certified, on Independent Medical Review.

 

Pasted from <http://www.dir.ca.gov/dwc/IMR/IMR-Decisions/IMR-Decisions2014/IMR2013_10001-20000/CM13-0019382.pdf>

 

TENS UNIT RENTAL:

 

Upheld

 

Claims Administrator guideline:

 

Decision based on MTUS Chronic Pain Treatment Guidelines.

 

MAXIMUS guideline: Decision based on MTUS Chronic Pain Treatment Guidelines Page(s): 117-121

 

Decision rationale:

 

California MTUS Guidelines state transcutaneous electrotherapy is not recommended as a primary treatment modality, but a one month home-based trial may be considered as a non-invasive conservative option. There should be evidence that other appropriate pain modalities have been tried and failed. As per the documentation submitted, there is no indication of an exhaustion of conservative treatment prior to the request for TENS therapy. There is also no evidence of a treatment plan including the specific short and long-term goals of treatment with the TENS unit. The specific frequency and duration of treatment was not provided in the request. Therefore, the request cannot be determined as medically appropriate. As such, the request is non-certified.

 

Pasted from <https://www.dir.ca.gov/dwc/IMR/IMR-Decisions/IMR-Decisions2014/IMR2014_30001-40000/CM14-0030846.pdf>

Decision rationale:

 

MTUS Chronic Pain Medical Treatment Guidelines do not recommend TENS as a primary treatment modality, but support consideration of a one-month home-based TENS trial used as an adjunct to a program of evidence-based functional restoration. Furthermore, criteria for the use of TENS includes pain of at least three months duration, evidence that other appropriate pain modalities have been tried (including medication) and failed, and a documented one-month trial period stating how often the unit was used, as well as outcomes in terms of pain relief and function. The documentation submitted for review does not indicate that the injured worker has underwent a TENS trial. The request is not medically

necessary and appropriate

 

Pasted from <https://www.dir.ca.gov/dwc/IMR/IMR-Decisions/IMR-Decisions2014/IMR2014_30001-40000/CM14-0031138.pdf>

 

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