N.D. Admin Code 92-01-02-29.1 - Medical necessity
1. A medical
service or supply necessary to diagnose or treat a compensable injury, which is
appropriate to the location of service, is medically necessary if it is widely
accepted by the practicing peer group and has been determined to be safe and
effective based on published, peer-reviewed, scientific studies.
2. Services that present a hazard in excess
of the expected medical benefits are not medically necessary. Services that are
controversial, obsolete, experimental, or investigative are not reimbursable
unless specifically preapproved or authorized by the organization. Requests for
authorization must contain a description of the treatment and the expected
benefits and results of the treatment.
3. The organization will not authorize or pay
for the following treatment:
a. Massage
therapy unless specifically preapproved or otherwise authorized by the
organization. Massage therapy must be provided by a licensed physical
therapist, licensed occupational therapist, or licensed chiropractor.
b. Chemonucleolysis; acupressure;
reflexology; rolfing; injections of colchicine except to treat an attack of
gout precipitated by a compensable injury; injections of chymopapain;
injections of fibrosing or sclerosing agents except where varicose veins are
secondary to a compensable injury; and injections of substances other than
cortisone, anesthetic, or contrast into the subarachnoid space (intrathecal
injections).
c. Treatment to
improve or maintain general health (i.e., prescriptions or injections of
vitamins, nutritional supplements, diet and weight loss programs, programs to
quit smoking) unless specifically preapproved or otherwise authorized by the
organization. Over-the-counter medications may be allowed in lieu of
prescription medications when approved by the organization and prescribed by
the health care provider and dispensed and processed according to the current
pharmacy transaction standard. Dietary supplements, including minerals,
vitamins, and amino acids are reimbursable if a specific compensable dietary
deficiency has been clinically established in the claimant. Vitamin B-12
injections are reimbursable if necessary because of a malabsorption resulting
from a compensable gastrointestinal disorder.
d. Articles such as beds, hot tubs, chairs,
Jacuzzis, vibrators, heating pads, home furnishings, waterbeds, exercise
equipment, cold packs, hot packs, and gravity traction devices are not
compensable except at the discretion of the organization under exceptional
circumstances.
e. Vertebral axial
decompression therapy (Vax-D treatment). f. Intradiscal electrothermal
annuloplasty (IDET).
g.
Prolotherapy (sclerotherapy).
h.
Surface electromyography (surface EMG).
i. Athletic trainer services that are
provided to a claimant via an agreement, or a contract of employment between a
trainer and a claimant's employer, or an entity closely associated with the
employer.
j. Spine strengthening
program (e.g. MedX or SpineX or other substantially equivalent
program).
k. Electrodiagnostic
studies performed by electromyographers who are not certified or eligible for
certification by the American board of electrodiagnostic medicine, American
board of physical medicine and rehabilitation, or the American board of
neurology and psychiatry's certification in the specialty of clinical
neurophysiology. Nerve conduction study reports must include either laboratory
reference values or literature-documented normal values in addition to the test
values to be eligible for payment.
l. Trigger point injections. No more than
twenty injections may be paid over the life of a claim. If a trigger point
injection is administered, the organization may not pay for additional
modalities such as cryotherapy and osteopathic manipulations performed in
conjunction with the trigger point injection. For purposes of this paragraph,
injections billed under CPT code 20552 or 20553 count as a single
injection.
m. Acupuncture therapy.
No more than eighteen treatments may be paid for the life of the claim. The
organization may waive this requirement in conjunction with programs designed
to ensure the ongoing evolution of managed care to meet the needs of injured
workers and providers.
n. Dry
needling.
o. Opioid therapy
exceeding ninety milligrams morphine equivalents daily unless the following
criteria are met when a prescription exceeding ninety milligrams morphine
equivalents daily is exceeded and as the organization deems necessary:
(1) Documented treatment plan consistent with
the organization's utilization review process;
(2) Participation in a psychosocial consult
with a health care provider, preferably a licensed psychologist or psychiatrist
outside the health care provider's network, to address the risk and harms of
opioid use under the centers for disease control and prevention "Guideline for
Prescribing Opioids for Chronic Pain". The psychosocial consult should include
standardized screening using validated tools for mental health and substance
abuse conditions, as well as a risk stratification plan; and
(3) Recent documentation of attempts to taper
opioid use and employ non-opioid therapies for pain control.
p. Benzodiazepine therapies
extending beyond a cumulative duration of four weeks, unless prescribed for
treatment of a compensable anxiety disorder. In addition, the following
criteria must be met when the cumulative duration of four weeks is exceeded and
as the organization deems necessary:
(1) A
documented treatment plan consistent with the organization's utilization review
process;
(2) Participation in a
psychosocial consult with a health care provider, preferably a licensed
psychologist or psychiatrist outside the health care provider's network, to
address the risk and harms of benzodiazepine use. The psychosocial consult
should include standardized screening using validated tools for mental health
and substance abuse conditions, as well as a risk stratification plan;
and
(3) Recent documentation of
attempts to taper benzodiazepine use and employ non-benzodiazepine
therapies.
Notes
General Authority: NDCC 65-02-08, 65-02-20, 65-05-07
Law Implemented: NDCC 65-02-20, 65-05-07, 65-05-40
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