The Colorado Division of Workers’ Compensation (DOWC) Medical Treatment Guidelines (MTGs) were developed to help healthcare providers render evidence-based and effective care for patients with work-related injuries. To be eligible for payment, treatments must be medically necessary, reasonable and directly related to a workers’ compensation injury. The MTGs help to establish criteria for the treatment’s medical necessity and reasonableness.
For injuries in which physical therapy, chiropractic, massage and acupuncture are reasonable treatment options, Pinnacol Assurance will limit initial payment approval to the number of sessions that corresponds to the initial time to produce effect (TPE) interval specified in the DOWC Medical Treatment Guidelines (Rule 16-5). For physical therapy, acupuncture and chiropractic treatment, the TPE is six sessions. For massage therapy, the TPE is three sessions (see Rule 17).
Payment for additional sessions will only be approved if (1) the authorized treating provider (ATP), who might be a chiropractor, makes a formal request for additional sessions, and (2) meaningful, objective and quantifiable evidence proves that functional gains have been realized during the sessions already provided. Specific actions include the following:
• Utilization review coordinators will notify physical therapists, chiropractors, massage therapists and acupuncturists that copies of their clinic notes must be submitted to Pinnacol for review as soon as possible after TPE intervals are reached. Utilization review coordinators will notify ATPs when TPE intervals are approaching and will request that ATPs review the results of therapeutic and chiropractic interventions.
• If sessions beyond the currently-approved number are required, the ATP should note the functional gains realized to date. They must substantiate the need for additional sessions when writing prescriptions for therapy. The utilization review coordinator will remind ATPs that it is their responsibility to determine the need for therapy and to write prescriptions — therapists themselves are not permitted to do this.
• Utilization review coordinators will carefully review therapeutic and chiropractic documentation to confirm that meaningful, measurable and specific functional gains are realized.
• If the requested documentation is not provided, or ATPs do not request additional sessions, the additional sessions will be issued an administrative denial of payment.
• If there is insufficient evidence of functional gain by the end of a TPE interval, utilization review coordinators can obtain independent expert reviews, which may result in denied payment for additional sessions.
• If functional gains are demonstrated, and ATPs have requested additional sessions, Pinnacol will approve additional sessions up to a subsequent TPE interval. Demonstration Time to Produce Effect Intervals and Functional Gains: Acupuncture, Chiropractic, Physical and Massage Therapy of objective and quantifiable functional gain, with the opportunity for continued and meaningful improvement, will be required before payment for additional sessions is approved.
There is strong evidence that active forms of therapy yield greater therapeutic benefits than passive forms of therapy (Rule 17, Exhibit 1, Section 2.e). An ATP who considers prescribing more than one treatment modality at a time (e.g., chiropractic and physical therapy) should be able to justify reasonableness and necessity (Rule 16-3 (D)). There is often significant overlap among therapeutic modalities. Simultaneous treatment can complicate assessments of which treatment is responsible for which benefit (or side effect), making it difficult to adjust the care plan as needed (Spencer-Bonilla et al., 2017). Also, simultaneous treatment typically requires more clinic appointments which can lead to increased work disruption.
This Pinnacol program intends to improve the quality of care and outcomes for injured workers by promoting improved communication between therapists, chiropractors and ATPs. The program promotes better medical record documentation and careful consideration of the DOWC’s MTG. ATPs are urged to explain to injured workers, as early and as clearly as possible, that while physical therapy and other forms of treatment might be prescribed for an initial period, this treatment should only continue if it produces genuine functional improvement.
The information provided by Pinnacol should not be interpreted as direction for the type or duration of medical treatment. A treating provider is expected to exercise independent medical judgment.
If you have any questions about this program, please contact Pinnacol’s Senior Medical Director, Dr. Tom Denberg, at tom.denberg@pinnacol.com, or contact Pinnacol’s Central Utilization Review team at central_ur@pinnacol.com or 303.361.4180.