This rule governs the identification
and medical management of claims necessitating supportive care, including
medical treatment reimbursement authorization. The objective is to ensure the
timely and efficient provision of medically necessary and appropriate treatment
reasonably related to the allowed conditions, in order to maintain or improve
the injured worker's level of function, minimize or prevent regression or
relapse, effectively manage symptoms, minimize disease or impairment
progression, provide continuity of care, and minimize reliance on medication
treatment.
(A)
As used in this rule, "supportive care" means care that
is medically necessary and that cannot be administered or performed by the
injured worker independently and is needed to maintain therapeutic benefit,
prevent or treat exacerbations, maintain function, or return to baseline
function.
(B)
A claim necessitating supportive care is a claim in
which the injured worker has reached a plateau in recovery and which requires
some level of ongoing care or medical treatment.
Such claims can be manifested by
reduced function due to ongoing impairment, pain, or distress related to the
allowed condition which diminishes quality of life, mobility, the ability to
perform activities of daily living (ADLs), or work activity.
(C)
The
MCO shall evaluate the request for supportive care services through a review of
the medical documentation in the file which must include the following
applicable information:
(1)
A comprehensive history and physical exam by the
physician of record or treating physician that includes:
(a)
The nature of the
reported symptoms of the allowed conditions, their onset, duration,
exacerbations, and any alleviating or aggravating
circumstances;
(b)
Objective findings of recent
examinations;
(c)
Report of current level of functioning using validated
instruments and tools to assess life function and disruption of function due to
the allowed conditions and the expected impact of the proposed plan of care on
the current limitations caused by the allowed conditions;
(d)
Prior treatment
and response to treatment, including the results of any withdrawal of
treatment; and
(e)
Confounding factors, if any, affecting treatment plan
decision-making.
(2)
Clinical
rationale for the treatment being requested;
(3)
A treatment plan
that includes:
(a)
A description of the interventions requested, including
proposed frequency and duration of treatment;
(b)
Lifestyle
modifications, if appropriate;
(c)
A description of
a home exercise program, if appropriate; and
(d)
Specific goals to
be achieved by the treatment being requested.
(D)
The
MCO shall consider the following while reviewing the medical documentation and
determining if the claim necessitates supportive care:
(1)
The allowed
conditions;
(2)
Changes in the injured worker's medical condition,
which have occurred over the course of care, if any, including medication
utilization, and physical and/or psychological function;
(3)
Improvement or
regression in function compared to baseline;
(4)
Any confounding
factors which may have impeded or aggravated the injured worker's progress;
and
(5)
Prior treatment and response to treatment, including
the results of any withdrawal of treatment.
(E)
The MCO shall,
when approving or denying a request for supportive care, consider and
document:
(1)
Prior industrial commission decisions relating to prior
requests for the same treatments;
(2)
Any new or
updated circumstances or information which support a different decision than
the prior decision(s) of the industrial commission;
(3)
Consistency or
lack thereof of the current treatment reimbursement request with previously
authorized requests; and
(4)
Denial of any request for supportive, non-surgical care
when a request for the same treatment has previously been granted by the
industrial commission must be supported by documentation as to how the injured
worker's current circumstances, which could include any new or updated
information, differ from those present or presented when the industrial
commission issued its order.
(F)
Frequency and
duration of medical treatment reimbursement requests for supportive care
meeting the criteria outlined in this rule shall be approved regardless of
whether they exceed treatment guidelines adopted by the bureau pursuant to rule
4123-6-16.1 of the
Administrative Code.
Notes
Ohio Admin. Code
4123-6-31.1
Effective:
2/1/2025
Five Year Review (FYR) Dates:
02/01/2030
Promulgated
Under: 119.03
Statutory
Authority: 4121.12,
4121.121,
4121.30,
4121.31,
4121.44,
4121.441,
4123.05,
4123.66
Rule
Amplifies: 4121.12,
4121.121,
4121.44,
4121.441,
4123.66
