Washington Administrative Code

Certain treatment procedures require authorization by the department or self-insurer. Requests for authorization must include a statement of: The condition(s) diagnosed; the current federally adopted ICD-CM codes; their relationship, if any, to the industrial injury/exposure; an …

The department or self-insurer will not allow nor pay for following treatment:(1) Use of diapulse, thermatic (standard model only), spectrowave and superpulse machines on workers entitled to benefits under the Industrial Insurance Act.(2) Iontophoresis; prolotherapy; injections o…

Chymopapain injections may be authorized in the treatment of lumbar disc disease under the following limitations and criteria:(1) Only physicians (a) who routinely care for patients with herniated lumbar intervertebral discs, (b) who are qualified by training and experience to di…

Authorization for inoculation or other immunological treatment for occupational disease shall be given only in cases in which a work related activity has resulted in probable exposure of the worker to a potential infectious occupational disease. In no case shall such inoculation …

In general, the department evaluates data on safety, health outcomes and cost-effectiveness for coverage. The department or self-insurer considers payment for drugs, including biologics and controlled substances, when:• The drug is used to treat the industrial injury or occupatio…

(1) Amount dispensed. The department or self-insurer will pay for no more than a thirty-day supply of a drug dispensed at any one time except in pension cases (see subsection (6) of this section) and claims that are held open for life-sustaining treatment. In these cases, up to a…

The department's outpatient drug coverage decisions are contained in the department's formulary, as developed by the department, in collaboration with the Washington state pharmacy and therapeutics committee and the industrial insurance medical advisory committee.In the formulary…

Some of the drugs that are routinely denied may be covered in special circumstances. Requests for coverage under special circumstances require authorization prior to treatment. Examples of drugs that may be covered in special circumstances include:• Drugs and medications to treat…

(1) Injectables. Prescriptions for injectable opioids or other analgesics, sedatives, antihistamines, tranquilizers, psychotropics, vitamins, minerals, food supplements, and hormones are not covered.Exceptions: The department or self-insurer covers injectable medications under th…

(1) The department or self-insurer may take any or all of the following steps when concerned about the amount or appropriateness of drugs the worker is receiving:• Notify the provider of concerns regarding the drugs such as interactions, adverse reactions, or prescriptions by oth…

Prescriptions must include the department authorized provider number for the prescribing physician and the physician's signature. The physician's record must contain the name and reason for the medication, the dosage, quantity prescribed and/or dispensed, the route of administrat…

In general, the department or self-insured employer pays for most drugs in an inpatient hospital setting. Please see WAC 296-20-075, Hospitalization.[Statutory Authority: RCW 51.04.020 and 51.04.030. WSR 00-01-040, § 296-20-03018, filed 12/7/99, effective 1/20/00.]

(1) Acute pain - Self-limiting pain that lasts from a few days to up to six weeks following an industrial injury or surgery.(2) Catastrophic injury - A severe injury from which recovery of physical function is not expected, such as a spinal cord injury.(3) Clinically meaningful i…

Checking the prescription monitoring program is recommended before prescribing opioids for new injuries. Providers must check the prescription monitoring program database, if available, and document before prescribing opioids in the subacute phase and repeat during chronic opioid…

Providers must administer a urine drug test and document results during the subacute phase and repeat at intervals according to the worker's risk category as described in the agency medical directors' group's guideline if prescribing chronic opioid therapy. The department or self…

When prescribing opioids, providers must use validated instruments to track and document the worker's function and pain status during the acute and subacute phase and routinely, at least every ninety days, to monitor the worker's status and response to chronic opioid therapy.[Sta…

The department or self-insurer is not responsible for the continuation of preinjury opioid use or any adverse outcomes which may result. For workers with preinjury chronic opioid therapy, payment for opioids beyond the acute phase will not be authorized except:• For catastrophic …

The department or self-insurer may cover opioids for up to six weeks when prescribed to treat pain from the acute industrial injury or after an authorized surgery. Providers must obtain and document the worker's baseline function and pain measurements during the acute phase if pl…

Before the department or self-insurer authorizes payment for opioids beyond the acute phase, the provider must perform and document the following:• Verify that the worker had clinically meaningful improvement in function and pain with the use of opioids in the acute phase.• If in…

Before the department or self-insurer authorizes payment for opioids beyond the subacute phase, the provider must perform, verify, and document the following best practices:• Clinically meaningful improvement in function has been established with opioid use in the acute or subacu…

Before the department or self-insurer authorizes continued payment for chronic opioid therapy, the provider must routinely, at least every ninety days or more frequently, according to the worker's risk, review the effects of opioids to determine whether therapy should continue an…

Before the department or self-insurer authorizes payment for chronic opioid therapy for a catastrophic injury (see WAC 296-20-03030 for the definition of catastrophic injury), the provider must perform, verify, and document the following:• A current signed pain treatment agreemen…

The department or self-insurer may pay for one pain-related emergency or urgent care visit related to the accepted condition for a worker already receiving opioid therapy, but payment for additional emergency or urgent care visits may be denied. Urgent care visit includes any uns…

The provider should taper the worker's total opioids to the preoperative dose or lower by six weeks after surgery. Upon request, and depending on the complexity of the surgery, the department or self-insurer may authorize an additional six weeks for the provider to taper opioids …

Continuing to prescribe opioids in the absence of clinically meaningful improvement in function or after the development of a severe adverse outcome, or prescribing opioids in escalating doses to the point of the worker developing opioid use disorder is not considered proper and …

The prescriber must discontinue opioids under the following circumstances:• The worker requests opioid discontinuation; or• The attending provider, because of concern for potential adverse outcomes, requests opioid discontinuation; or• The worker is maintained on opioids for at l…

The department or self-insurer may pay for adjuvant treatment to aid with the weaning (see WAC 296-20-03030 for the definition of step 1 and 2 taper) or detoxification process, except for ultra-rapid detoxification (e.g., detoxification within three days using antagonist drugs wi…

The department or self-insurer may authorize payment for addiction management through a licensed chemical dependency treatment center for up to six months as an aid to recovery if the following conditions are met:• The worker has failed steps 1 and 2 taper (see WAC 296-20-03030 f…

Conditions requiring treatment beyond 60 days are indicative of a major industrial condition or complication by other conditions. Except in cases of severe and extensive injuries, i.e., quadriplegia, paraplegia, multiple fractures, etc., when the worker requires treatment beyond …

In the event of complication, controversy, or dispute over the treatment aspects of any claim, the department or self-insurer will not authorize treatment until the attending doctor has arranged a consultation with a qualified doctor with experience and expertise on the subject, …

In cases presenting diagnostic or therapeutic problems to the attending doctor, consultation with a specialist will be allowed without prior authorization. The consultant must submit his findings and recommendations immediately to the attending doctor and the department or self-i…

Conditions preexisting the injury or occupational disease are not the responsibility of the department. When an unrelated condition is being treated concurrently with the industrial condition, the attending provider must notify the department or self-insurer immediately and submi…

The department or self-insurer requires different kinds of information at various stages of a claim in order to approve treatment, time-loss compensation, and treatment bills. The information provided in these reports is needed to adequately manage industrial insurance claims.Thi…

For services or provider types where the department has established the provider network, the injured worker must select an attending provider from the provider network for all care beyond the initial visit. If the initial office or emergency room visit was completed with a nonne…

In some cases, treatment by more than one practitioner may be allowed. The department or self-insurer will consider concurrent treatment when the accepted conditions resulting from the injury involve more than one system and/or require specialty or multidisciplinary care.When req…

(1) Hospitalization will be paid for proper and necessary medical treatment of the accepted condition(s). The department may develop and implement utilization management criteria which will be used to review inpatient hospital admissions. Reimbursement for hospitalization is limi…

Elective surgery for an unrelated condition is not normally permitted during hospitalization for an industrial condition. Under some circumstances unrelated elective surgery may be permitted through prior agreement and approval by the department provided the unrelated surgery is …

A worker temporarily totally disabled or permanently totally disabled may either temporarily or permanently require home nursing care. A physician's request and prior department authorization are required for home nursing care.Home health, hospice, and home care agency providers …

When a claim has been closed by the department or self-insurer by written order and notice for 60 days, submission of a formal "application to reopen claim due to worsening of condition" form # F242-079-000 is preferred. The department or self-insurer is responsible for customary…

On occasion, a claim may be closed prematurely or in error or other adjudication action may be taken, which may seem inappropriate to the attending provider or injured worker. When this occurs the attending provider should submit immediately in writing a request for reconsiderati…

The department or self-insurer will be responsible one time for replacement of glasses or contact lenses only to the extent of the cost of restoring damaged item to its condition at the time of the accident. This benefit applies only if the worker was wearing the glasses or conta…

Only dentists, oral surgeons or dental specialists licensed in the state in which they practice are eligible to treat workers entitled to benefits under the industrial insurance law.If only a dental injury is involved, the doctor's portion of the report of accident must be comple…

The department or self-insurer is responsible for replacement or repair of hearing aids damaged or lost due to an industrial accident only to the extent of restoring the damaged item to its condition at time of the accident. If the hearing aid is repairable and the worker determi…

The department or self-insurer will authorize and pay rental fee for equipment or devices if the need for the equipment will be for a short period of treatment during the acute phase of condition. Rental extending beyond 60 days requires prior authorization. If the equipment will…

(1) The department or self-insurer will reimburse travel expense incurred by workers for:(a) Examinations at department's or self-insurer's request;(b) Approved vocational retraining or vocational services at department's or self-insurer's request;(c) Fitting of prosthetic device…

Procedures not specifically listed will be given values comparable to those of the listed procedures of closest similarity. Refer to chapter 296-20 WAC (including the definition section) and the fee schedules for required billing documentation.[Statutory Authority: RCW 51.04.020,…

(1) The department or self-insurer may from time to time enter into special agreements for services provided by, or under the direction of, licensed providers authorized to bill the department. Special agreements are for services other than routine services covered under the fee …

Recognizing the greatest need for access to X-rays lies with the attending provider, the department or self-insurer requires only submission of X-ray findings and does not require submission of the actual films except upon specific request when needed for purposes of permanent di…

(1) No payment will be made for treatment or medication on rejected claims except:(a) Services which were carried out at the specific request of the department or the self-insurer; or(b) Examination or diagnostic services which served as a basis for the adjudication decision; or(…

For providers or services not subject to the health care provider network requirements, including treatment at the initial office or emergency room visit, a provider must obtain a provider account number from the department.(1) How can a provider obtain a provider account number …