La. Admin. Code tit. 40 § I-2115

Current through Register Vol. 50, No. 3, March 20, 2024

Section I-2115 - Maintenance Management

A. Successful management of chronic pain conditions results in fewer relapses requiring intense medical care. Failure to address long-term management as part of the overall treatment program may lead to higher costs and greater dependence on the health care system. Management of CRPS and CPD continues after the patient has met the definition of maximum medical improvement (MMI). MMI is declared when a patient's condition has plateaued and the authorized treating physician believes no further medical intervention is likely to result in improved function. When the patient has reached MMI, a physician must describe in detail the maintenance treatment.

B. Maintenance care in CRPS and CPD requires a close working relationship between the carrier, the providers, and the patient. Providers and patients have an obligation to design a cost-effective, medically appropriate program that is predictable and allows the carrier to set aside appropriate reserves. Carriers and adjusters have an obligation to assure that medical providers can design medically appropriate programs. Designating a primary physician for maintenance management is strongly recommended.

C. Maintenance care will be based on principles of patient self-management. When developing a maintenance plan of care, the patient, physician and insurer should attempt to meet the following goals:

1. maximal independence will be achieved through the use of home exercise programs or exercise programs requiring special facilities (e.g., pool, health club) and educational programs;

2. modalities will emphasize self-management and self-applied treatment;

3. management of pain or injury exacerbations will emphasize initiation of active therapy techniques and may occasionally require anesthetic injection blocks;

4. dependence on treatment provided by practitioners other than an authorized treating physician will be minimized;

5. reassessment of the patients function must occur regularly to maintain daily living activities and work function;

6. patients will understand that failure to comply with the elements of the self-management program or therapeutic plan of care may affect consideration of other interventions.

D. It is recommended that valid functional tests are used with treatments to track efficacy. The following are specific maintenance interventions and parameters.

1. Home Exercise Programs and Exercise Equipment. Most patients have the ability to participate in a home exercise program after completion of a supervised exercise rehabilitation program. Programs should incorporate an exercise prescription including the continuation of an age-adjusted and diagnosis-specific program for aerobic conditioning, flexibility, stabilization, and strength. Many patients will benefit from several booster sessions per year, which may include motivational interviewing and graded activity.

a. Some patients may benefit from the purchase or rental of equipment to maintain a home exercise program. Determination for the need of home equipment should be based on medical necessity to maintain MMI, compliance with an independent exercise program, and reasonable cost. Before the purchase or long-term rental of equipment, the patient should be able to demonstrate the proper use and effectiveness of the equipment. Effectiveness of equipment should be evaluated on its ability to improve or maintain functional areas related to activities of daily living or work activity. Prior to purchasing the equipment a physical therapist who has treated the patient may visit a facility with the patient to assure proper use of the equipment. Occasionally, compliance evaluations may be made through a four-week membership at a facility offering similar equipment. Home exercise programs are most effective when done three to five times a week.

2. Exercise Programs Requiring Special Facilities. Some patients may have higher compliance with an independent exercise program at a health club versus participation in a home program. All exercise programs completed through a health club facility should focus on the same parameters of an age-adjusted and diagnosis-specific program for aerobic conditioning, flexibility, stabilization, and strength. Selection of health club facilities should be limited to those able to track attendance and utilization, and provide records available for physician and insurer review. Prior to purchasing a membership, a physical therapist who has treated the patient may visit a facility with the patient to assure proper use of the equipment.

a. frequency: two to three times per week;

b. maximum maintenance duration: three months. Continuation beyond three months should be based on functional benefit and patient compliance. Health club membership should not extend beyond three months if attendance drops below two times per week on a regular basis.

3. Patient Education Management. Educational classes, sessions, or programs may be necessary to reinforce self-management techniques. This may be performed as formal or informal programs, either group or individual:

a. maintenance duration: two to six educational sessions during one 12-month period.

4. Psychological Management. An ideal maintenance program will emphasize management options implemented in the following order: individual self-management (pain control, relaxation and stress management, etc.); group counseling; individual counseling by a psychologist or psychiatrist; and in-patient treatment. Exacerbation of the injury may require psychological treatment to restore the patient to baseline. In those cases, use treatments and timeframe parameters listed in the Biofeedback and Psychological Evaluation or Intervention sections:

a. maintenance duration: 6 to 10 visits during the first year and four to six visits per year thereafter. In cases of significant exacerbation or complexity, refer to Section G.15, on psychological treatment.

5. Non-opioid Medication Management. In some cases, self-management of pain and injury exacerbations can be handled with medications, such as those listed in the Medication section. Physicians must follow patients who are on any chronic medication or prescription regimen for efficacy and side effects. Laboratory or other testing may be appropriate to monitor medication effects on organ function:

a. maintenance duration: usually, four medication reviews within a 12-month period. Frequency depends on the medications prescribed. Laboratory and other monitoring as appropriate.

6. Opioid Medication Management. In very selective cases, scheduled opioids or an implanted programmable pump with different medications including opioids may prove to be the most cost effective means of insuring the highest function and quality of life; however, inappropriate selection of these patients may result in a high degree of iatrogenic illness including addiction and drug overdose. A patient should have met the criteria in the opioids section of these guidelines before beginning maintenance opioids. Laboratory or other testing may be appropriate to monitor medication effects on organ function. The following management is suggested for maintenance opioids:

a. The medications should be clearly linked to improvement of function, not just pain control. All follow-up visits should document the patients ability to perform routine functions satisfactorily. Examples include the abilities to: perform: work tasks, drive safely, pay bills or perform basic math operations, remain alert and upright for 10 hours per day, or participate in normal family and social activities. If the patient is not maintaining reasonable levels of activity the patient should usually be tapered from the opioid and tried on a different long-acting opioid.

b. A low risk opioid medication regimen is defined, as less than 50 MED per day. This may minimally increase or decrease over time. Dosages will need to be adjusted based on side effects of the medication and objective function of the patient. A patient may frequently be maintained on non-opioid medications to control side effects, treat mood disorders, or control neuropathic pain; however, only one long-acting opioid and one short-acting opioid for rescue use should be prescribed. Buccally absorbed opioids other than buprenorphine are not appropriate for these non-malignant pain patients. Transdermal opioid medications are not recommended, other than buprenorphine.

c. All patients on chronic opioid medication dosages need to sign an appropriate opioid contract with their physician for prescribing the opioids.

d. The patient must understand that continuation of the medication is contingent on their cooperation with the maintenance program. Use of non-prescribed drugs may result in tapering of the medication. The clinician should order random drug testing at least annually and when deemed appropriate to monitor medication compliance.

e. Patients on chronic opioid medication dosages must receive them through one prescribing physician:

i. maintenance duration: 12 visits within a 12-month period to review the opioid plan. Laboratory and other monitoring as appropriate.

7. Therapy Management. Some treatment may be helpful on a continued basis during maintenance care if the therapy maintains objective function and decreases medication use. With good management, exacerbations should be uncommon; not exceeding two times per year and using minimal or no treatment modality beyond self-management. On occasion, exacerbated conditions may warrant durations of treatment beyond those listed below. Having specific goals with objectively measured functional improvement during treatment can support extended durations of care. It is recommended that if after six to eight visits no treatment effect is observed, alternative treatment interventions should be pursued:

a. maintenance duration: Active Therapy, Acupuncture, or Manipulation: 10 visits [for each treatment] during the first year and then decreased to five visits per year thereafter.

8. Injection Therapy

a. Trigger Point Injections and Dry Needling. These injections or dry needling may occasionally be necessary to maintain function in those with myofascial problems:

i. maintenance duration for trigger point injections: not more than four injections per session not to exceed four sessions per 12-month period;

ii. maintenance duration for dry needling: no more than one to three times per week not to exceed 14 treatments within six months.

b. Epidural and Selective Nerve Root Injections. Patients who have experienced functional benefits from these injections in the past may require injection for exacerbations of the condition. Recall that the total steroid injections at all sites, including extremities, should be limited to 3-4 mg/kg per rolling 12 months to avoid side effects from steroids:

i. maintenance duration: two to four injections per 12-month period. For chronic radiculopathy or post herpetic neuralgia or intercostal neuralgia, injections may be repeated only when a functional documented response produces a positive result. A positive result could include positive pain response, a return to baseline function as established at MMI, return to increased work duties, and measurable improvement in physical activity goals including return to baseline after an exacerbation. Injections may only be repeated when these functional and time goals are met and verified by the designated primary physician.

c. Time frames for zygapophyseal (Facet) injections:

i. maintenance duration: four injections per year and limited to three joint levels either unilaterally or bilaterally as in facet joint and medial branch facet joint. injections may be repeated (instead of proceeding with RF) only when a functional documented response lasts for three months. A positive result would include a return to baseline function as established at MMI, return to increased work duties, and a measurable improvement in physical activity goals including return to baseline after an exacerbation. Injections may only be repeated when these functional and time goals are met and verified by the designated primary physician.

d. Time frames for radiofrequency medial branch neurotomy/facet rhizotomy and sacroiliac joint (lateral branch neurotomy and other peripheral nerves listed in these rules:

i. maintenance duration: two times per year not exceeding three levels. The patient must meet the criteria as described in radio frequency denervation. The initial indications including repeat blocks and limitations apply. The long-term effects of repeat rhizotomies, especially on younger patients are unknown. In addition, the patient should always reconsider all of the possible permanent complications before consenting to a repeat procedure. There are no studies addressing the total number of RF neurotomies that should be done for a patient. Patient should receive at least six months with improvement of 50 percent or more in order to qualify for repeat procedures;

ii. optimum/maximum maintenance duration: twice a year after the initial rhizotomy.

9. Purchase or Rental of Durable Medical Equipment (DME). It is recognized that some patients may require ongoing use of self-directed modalities for the purpose of maintaining function and/or analgesic effect. Purchase or rental of modality based equipment should be done only if the assessment by the physician and/or physical/occupational therapist has determined the effectiveness, compliance, and improved or maintained function by its application. It is generally felt that large expense purchases such as spas, whirlpools, and special mattresses are not necessary to maintain function.

10. Implanted programmable pumps or implanted spinal cord stimulators. facet pain, sacroiliac joint pain, genicular nerve pain, peripheral nerve pain and occasional acute exacerbation of radicular pain is common in patients with these implanted devices. It is necessary to continue to treat previously treated genicular nerve pain, facet pain, sacroiliac joint pain, peripheral nerve pain and occasional radicular pain with injections, and maintenance RF ablation and occasional Epidural injections as listed elsewhere in these rules. The presence of these implanted devices does not preclude diagnosis and treatment of these conditions as well as maintenance of these conditions both before and after implantation of these devices. Also these implanted devices require regular maintenance, adjustments; pump refills every one to six months, stimulator adjustments and management for the life of these devices.

La. Admin. Code tit. 40, § I-2115

Promulgated by the Louisiana Workforce Commission, Office of Workers Compensation Administration, LR 37:1713 (June 2011), Amended LR 46250 (2/1/2020), Repromulgated LR 46399 (3/1/2020).

AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1203.1.