Section 20-2-III - MEDICAL NECESSITYThe concept of medical necessity is the foundation of all treatment and reimbursement made under the provision of § 71-3-15, Mississippi Code of 1972, as amended. For reimbursement to be made, services and supplies must meet the definition of "medically necessary." The sole use of extraneous guidelines, including but not limited to the ODG guidelines, to determine the appropriateness or extent of treatment or reimbursement is prohibited. Continuation of treatment shall be based on the concept of medical necessity and predicated on objective or appropriate subjective improvements in the patient's clinical status. Arbitrary limits on treatment or reimbursement based solely on diagnosis or guidelines outside this Fee Schedule are not permitted.
A. For the purpose of the Workers' Compensation Program, any reasonable medical service or supply used to identify or treat a work-related injury/illness which is appropriate to the patient's diagnosis, is based upon accepted standards of the health care specialty involved, represents an appropriate level of care given the location of service, the nature and seriousness of the condition, and the frequency and duration of services, is not experimental or investigational, and is consistent with or comparable to the treatment of like or similar non-work related injuries, is considered "medically necessary." The service must be widely accepted by the practicing peer group, based on scientific criteria, and determined to be reasonably safe. It must not be experimental, investigational, or research in nature except in those instances in which prior approval of the payer has been obtained. For purposes of this provision, "peer group" is defined as similarly situated physicians of the same specialty, licensed in the State of Mississippi, and qualified to provide the services in question. B. Services for which reimbursement is due under this Fee Schedule are those services meeting the definition of "medically necessary" above and includes such testing or other procedures reasonably necessary and required to determine or diagnose whether a work-related injury or illness has been sustained, or which are required for the remedial treatment or diagnosis of an on-the-job injury, a work-related illness, a pre-existing condition affected by the injury or illness, or a complication resulting from the injury or illness, and which are provided for such period as the nature of the injury or process of recovery may require. C. Treatment of conditions unrelated to the injuries sustained in an industrial accident may be denied as unauthorized if the treatment is directed toward the non-industrial condition or if the treatment is not deemed medically necessary for the patient's rehabilitation from the industrial injury. D. Services that are experimental or investigational, including but not limited to CPT Category II and Category III codes, are not reimbursable for this Fee Schedule. Please refer to the MWCC website (www.mwcc.ms.gov [File Link Not Available]) for a list of some of these procedures.20 Miss. Code. R. § 2-III