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Ensuring functional gains with PT/OT

Often, quality care for injured workers includes therapeutic activities to enhance the worker’s

December 11, 2020
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Often, quality care for injured workers includes therapeutic activities to enhance the worker’s mobility, body mechanics, coordination, employability and sensory motor integration. The Colorado Division of Workers’ Compensation Medical Treatment Guidelines (Rule 17) sets the expectation of improved function in patients referred for physical therapy (PT), occupational therapy (OT) and/or massage therapy (MT).

The expected time to produce results, the frequency of treatments and the optimum and maximum duration of the interventions are addressed in the “time to produce effect” section of the exhibit guidelines.

Functional gains that can be objectively measured include:

• Increased ability to perform activities of daily living

• Decrease in opioid or medication use

• Increased range of motion, coordination, strength, endurance and/or positional tolerances

• Decreased work restrictions for modified duties and return to work

• Subjective reports of decreased pain and increased function when correlated with objective findings

Providers should send written documentation of the achieved functional gains. A letter of medical necessity and relatedness is required to continue therapy beyond the initial provider prescription and for any cases that have exceeded therapy treatment or are about to exceed the treatment guideline thresholds.

This policy is not intended to direct the type or duration of the prescribed medical care. As the primary care provider, you should exercise independent medical judgment in determining the appropriate medical care necessary to treat your patients.

Utilization Standards: Rule 16-6(C)(1-2) Notification - Adopted rule effective 1/1/2021

The Payer may limit its approval of initial treatment to the number or duration specified in the relevant Medical Treatment Guideline(s) without a medical reviewer. If subsequent medical records document functional progress, additional treatment should be approved.

If payer proposes to discontinue treatment before the maximum number of treatments/treatment duration has been reached due to lack of functional progress, payer shall support that decision with a medical review compliant with this rule.

If you have any questions or need additional information, please contact Pinnacol Assurance at or 303.361.4945.

COVID-19 policy update