Work comp: Medical benefits -- treatment parameters

• Minnesota Rules 5221.6010 through 5221.6600

Treatment parameters apply to all dates of injury and all health care providers. The parameters establish guidelines for reasonable treatment of employees with compensable injuries and facilitate communication between the health care provider and the insurer. The parameters assist insurers and health care providers to identify services that are performed at a level or frequency that is excessive, unnecessary or inappropriate based on accepted medical standards.

The parameters do not affect determinations of liability and do not apply to denied treatments. If the insurer reverses a denial, the parameters apply to all treatment after the claim has been accepted.

The parameters were established for common work-related injuries:  low back pain, neck pain, thoracic back pain, upper extremity disorders and reflex sympathetic dystrophy. The parameters also include broad guidelines that reflect standard medical practice.

General treatment parameters

All treatment must be medically necessary. The health care provider must assess the employee's condition through ongoing evaluations. A key treatment parameter concept is effective care, which means the patient is improving subjectively, the patient's objective clinical findings are improving and/or the patient's functional status is improving (such as workability). For care to be deemed effective, two of the three improvements must be occurring. If care is not effective, the provider must reassess the case and then stop care, alter the treatment plan or refer the patient to another appropriate provider.

The health care provider must use the least intensive appropriate setting and enable the employee to become independent in his or her own care. Providers must also be diligent in watching and referring (as necessary) any employee who might be or become chemically dependent upon any medication prescribed.

Specific parameters

Specific treatment parameters apply to the following:

• medical imaging;

• medications;

• long-term treatment with opioids;

• low back pain;

• neck pain;

• thoracic back pain;

• upper extremity disorders;

• reflex sympathetic dystrophy;

• inpatient hospitalization;

• surgical procedures; and

• chronic management.

The treatment parameters for specific body parts address three stages of treatment:

• initial nonsurgical;

• surgical evaluation; and

• chronic management.

The initial nonsurgical stage can include passive care, such as physical therapy or chiropractic treatment, and active care, such as exercise, injections and medications. Medical conditions that have not improved at the conclusion of the initial nonsurgical phase may be referred for imaging, such as an MRI or CT scan (unless imaging is needed sooner) and may be evaluated for surgery or other treatment. If symptoms and disability continue and the health care provider believes surgery is not required, or where surgery has been refused or has failed, the employee may enter into the chronic management phase. The emphasis during this phase is meant to focus on restoration of maximum functional status.

Parameters for surgery

The health care provider must give the insurer prior notification before proceeding with any elective inpatient surgery. Emergency surgery may proceed without prior notification. Health care providers often ask the insurer to approve surgery before it takes place to ensure that the bills will paid. However, the reasonableness and necessity of any surgery can be reviewed after the surgery has taken place, based on the medical information that was available at the time.

Departures from treatment parameters

In certain circumstances, it is appropriate to depart from the treatment parameters regarding the duration or type of treatment. These include:

• a documented medical complication;

• a need for additional treatment to assist the employee in the initial return to work where the employee's work activities place stress on the part of the body affected by the work injury;

• treatment that continues to meet two of the following criteria documented by medical records:

  • an employee's subjective complaints are improving,

  • an employee's objective complaints are improving or

  • an employee's functional status is objectively improving; or

• an incapacitating exacerbation of the employee's condition.