W. Va. Code R. § 85-20-50

Current through Register Vol. XLI, No. 24, June 14, 2024

Section 85-20-50 - Treatment Guidelines: Interventional Management of Chronic Pain

Definitions:

As used in this exempt legislative rule, the following terms have the stated meanings unless the context of a specific use clearly indicates another meaning is intended.

50.1. "Acute pain" means pain experienced as the result of injury, disease, or operative procedure. Treatment usually consists of medications, surgical repair, and/or physical medicine therapies. Care may be provided in the office, clinic, or hospital setting.

50.2. "Bier block" means the instillation of medication into the venous system of a limb for anesthetic or therapeutic purposes; venous circulation is occluded with a tourniquet to retain medication in the veins of the limb.

50.3. "Chronic pain" means pain lasting more than three months. The cause of the pain is often unknown and may not be linked to an actual physiological event. Chronic pain complaints are usually accompanied by other psychophysiological disorders such as depression, weight gain or loss, sleep disorder and digestive disorder. A nurse case manager must coordinate care for claimants experiencing chronic pain, including intervention by a pain management specialist early in the treatment process and involvement of other treatment modalities and consultative specialists as needed.

50.4. "Interdisciplinary" means including representation from two or more health care fields.

50.5. "Medical Services Unit" or "Office of Medical Services" means a group of Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, personnel designated to deal with health care issues; such personnel may be supplemented with health care personnel providing services on a contract or other basis.

50.6. "Nerve block" means injection of a local anesthetic medication in proximity to a nerve or nerve plexus to block nerve transmission.

50.7. "Nurse Case Manager" means a duly licensed registered professional nurse authorized by the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, to coordinate health care and rehabilitative services for injured workers.

50.8. "Pain" refers to a complex unpleasant sensory and emotional experience associated with actual or potential tissue damage or which may just be a subjective experience described in terms of such damage.

50.9. "Pain management specialist" means a licensed physician with specialized training and experience in the diagnosis and/or treatment of chronic pain.

50.10. "Steady dose" refers to the amount and frequency of pain relief medication that is required to maintain optimum pain relief, once the dosage of such medication has become fixed or nearly fixed in amount and frequency.

50.11. "Trigger point injection" means placement of a needle into a myofascial space with or without injection of medication.

General:

50.12. All practitioners who treat chronic pain need to address goals in three major life areas: physical; social; and psychological.

a. Physical goals include: analgesia, early mobility, functional restoration and increased exercise tolerance, strength and range of motion.

b. Social goals include: a positive expectation for recovery from family and support systems; avoiding identification with disabled family prototypes; resistance to the negative reinforcement from interested other parties; and recognition of the deleterious effects of the disability lifestyle.

c. Psychological goals include: dealing with grief and loss over altered function and coping with chronic distress and a changed lifestyle; maintaining a positive attitude toward recovery; focusing motivation; appreciating primary, secondary and tertiary gains; and obtaining diagnosis and treatment for any psychiatric diagnosis.

50.13. Emergency conditions such as Complex Regional Pain Syndrome (Reflex Sympathetic Dystrophy) may require immediate consultation with a pain specialist and initiation of treatment without delay.

50.14. In contusion and sprain/strain cases, and in non-surgical disk cases, claimants who are being considered for injections for the treatment of chronic pain, but who have not had a trial of physical medicine, including exercise and/or manipulation, will be required to be evaluated by a physical medicine practitioner or other independent medical evaluator. The physical medicine practitioner or other evaluator will determine whether a 30-day regimen of physical medicine in conjunction with initiation of chronic pain therapy is likely to provide full or partial relief prior to initiating a series of injections.

50.15. When chronic pain patients do not respond to initial specialist-directed efforts, a nurse case manager may be assigned to coordinate the pain management effort. The nurse case manager's or other case manager's report will include an assessment as to the benefits of chronic pain management, such as the likelihood that the claimant will be able to return to work. A psychiatric or psychological evaluation must be part of the assessment process. Psychiatric conditions must be evaluated and under treatment as indicated before use of long-term narcotics or implantable devices will be authorized by the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable.

50.16. Claimants who have injuries greater than six (6) months old with continued symptoms, and who are not actively being treated for chronic pain may be eligible for an additional six (6) months further treatment or management of pain, only if an independent medical evaluator selected by the injured worker's treating physician agrees that the recommended treatment, including pain management, is reasonable, necessary, related to the compensable injury, and likely to be successful in substantially reducing the injured worker's symptoms.

Injections:

The following criteria must be met before the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, will authorize the use of injections by the pain management specialist form the treatment plan:

50.17. The Claim file must document objective physical signs and subjective symptoms which support the use of the proposed procedure.

50.18. When performing a "series" of injections, there must be documentation of measurable physical, psychological or vocational improvement before performing the next injection. Treatment of low back pain requires that a complete Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, back form be in the injured worker's file.

50.19. Active, not passive, physical medicine and home exercises prescribed after documented demonstration to the prescribing provider are to be a part of any injection or procedure-based treatment plan. A report from the provider must be sent to the physician and a copy to the claims manager after every fourth visit. If physical medicine is not recommended, the physician must explain why it is not going to be used. Pain management shall be terminated if the injured worker fails to fully cooperate with the required exercise program.

50.20. If a surgical spine lesion exists that shows no immediate neurologic danger, cervical epidural steroids may be considered prior to surgery. The surgeon and the pain management specialists should work collaboratively in such cases. If epidural injections fail to provide relief or if new neurological deficits develop, surgical, evaluation should be scheduled promptly. The treating physician is responsible for referring any suspected surgical lesion promptly to a surgeon.

50.21. The treatments under each of the following categories are deemed appropriate. The order in which the treatments within each category are listed is not controlling of the treatment plan except as indicated.

Head and Neck Pain:

50.22. Peripheral Nerves, including occipital, greater and lesser, auricular, supraorbital, maxillary branch of V, mandibular branch of V, and others.

a. Six (6) blocks over three (3) months in office, or in ambulatory clinic if fluoroscopy is required;

b. Neurolysis/ Denervation by cryotherapy, chemical means, radiofrequency, or surgical intervention if good response not substained.

50.23. Facial Pain Sympathetically maintained

a. Sphenopalatine ganglion block-six (6) blocks over three (3) months;

b. Stellate ganglion block-six (6) blocks over three (3) months

50.24. Intrathecal Opioids- if all other conservative treatments fail

a. A trial is required. Refer to specific guidelines.

b. A second opinion is required before implant.

50.25. Myofascial Pain

a. Trigger point injections, no more than six (6) points or no more than six (6) occasions in three (3) months. If authorization for trigger point injections are requested more than twice in 1 year or 4 cycles total, the claim may be assigned a nurse case manager. Authorization is at the discretion of the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, after review of the case and focus on the claimant's work record.

b. Home exercise and physical medicine is required in combination with trigger point injections.

50.26. Cervical Facet Mediated Pain.

a. No more than 4 injections over six (6) months.

b. Physical medicine is required in combination with injections.

c. Neurolysis/ Denervation by cryotherapy, chemical means, radiofrequency or surgical intervention if good response to anesthetic injections not sustained.

50.27. Cervical Radiculopathy

a. Cervical epidural steroids, no more than four (4) injections in a six (6) month period, if surgery in accordance with the appropriate Workers' Compensation treatment guideline is not a medically viable option or if surgery has been attempted and failed to provide relief;

b. Cervical epidural infusion

c. If physical medicine alone fails in 30 days, suprascapular nerve block should be considered.

d. Spinal cord stimulation if other treatments fail. See specific guidelines.

Shoulder And Upper Extremity:

50.28. Adhesive Capsulitis.

a. Physical medicine alone should be used initially;

b. If physical medicine alone fails, distention by injection or a local nerve block may be performed combined with a follow-up exercise program.

50.29. Subdeltoid Bursitis, Olecranon Bursitis- No more than three (3) injections over six (6) months.

50.30. Epicondylitis - No more than three (3) injections over six (6) months.

50.31. Myofascial Pain

a. Trigger point injections, no more than six (6) points or no more than six (6) occasions in three (3) months;

b. If trigger point injections need to be repeated more than twice in (one) 1 year or for more than four (4) cycles total, a nurse case manager will be assigned to the claim. Authorization is at the discretion of the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable.

c. Home exercise and physical medicine is required in combination with trigger point injections.

50.32. Phantom pain or stump pain.

a. Stellate ganglion block, up to six (6) times over a three (3) month period;

b. Cervical epidural catheter with infusion, for not more than four (4) weeks;

c. Spinal cord stimulation per specific guidelines if the above therapies fail.

50.33. Complex regional pain syndrome (reflex sympathetic dystrophy)

a. Referral to specialist made immediately upon diagnosis;

b. Cervical epidural infusion in conjunction with a program of physical medicine therapy no more than four (4) weeks duration;

c. Spinal cord stimulation in accordance with specific guidelines;

d. Stellate ganglion block, up to twelve (12) times during a three (3) month period;

e. Bier block, up to six (6) times over a three (3) month period.

50.34. Peripheral nerve injury

a. Nerve block, up to six (6) times over a three (3) month period;

b. Bier blocks up to six (6) times over a three (3) month period;

c. Cervical epidural infusion with physical medicine therapy of no more than four (4) weeks duration;

d. Spinal cord stimulation in accordance with specific guidelines.

50.35. Carpal Tunnel Syndrome

a. Nerve block up to six (6) times over a three (3) month period, if surgery in accordance with the Commission's, Insurance Commissioner's, private carrier's or self-insured employer's, whichever is applicable, treatment guideline is not a medically viable option or if surgery has been attempted and failed to provide relief.

50.36. Other Causes of Extremity Pain

a. Treatment on a case by case basis, subject to review by the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable.

Thoracic and Chest Wall Pain:

50.37. Thoracic Disc Syndrome

a. Thoracic epidural steroids injection, up to four (4) times over six (6) months, if surgery is not a medically viable option, in the sole discretion of the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, or if surgery has been attempted and failed to provide relief.

b. Thoracic epidural infusion, accompanied by physical medicine if epidural steroids fail.

50.38. Intercostal Neuralgia

a. Intercostal nerve block with local steroids, up to four (4) times over six (6) months;

b. Thoracic epidural steroids, up to four (4) times over six (6) months;

c. Neurolytic intercostal injection if good but nonsustained improvement with steroid injections;

d. Spinal cord stimulation as per specific guidelines.

50.39. Costochondritis

a. Injection of joint, up to four (4) times over six (6) months;

b. Concurrent treatment by physical medicine is required.

Abdominal Pain:

50.40. Traumatic pancreatitis

a. Celiac plexus blocks, up to six (6) times over six (6) months;

b. Neurolytic celiac plexus blocks if a good but unsustained response results from celiac plexus blocks with local anesthetic;

c. Intrathecal opioids. See specific guide lines.

50.41. Post Hernia Nerve Entrapment-Injection of involved nerve, up to six (6) times over three (3) month period

50.42. Peripheral nerve involvement

a. Injection of ilioinguinal, genitofemoral, iliohypogastric, or other peripheral nerves, up to six (6) times over (3) months

b. Spinal cord stimulation in accordance with specific guidelines.

50.43. Pelvic/ Rectal/ Penile/ Vulvar pain

a. Superior hypogastric plexus block, up to four (4) times over a three (3) month period;

b. Intrathecal opioids - see specific guidelines

c. Peripheral nerve block as approved by the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable.

Low back-Lumbar pain:

50.44. Lumbar Facet Joint Syndrome

a. Injections of facets, up to four (4) times over a six (6) month period, with physical medicine or home exercise. If this needs to be repeated more than twice in a one (1) year or for more than four (4) cycles total, a nurse case manager will be assigned to the claim. Authorization for continued treatment is at the discretion of the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable.

b. Neurolysis/ Denervation by cryotherapy, chemical means , radio-frequency, or surgical intervention if complete pain relief following injections is not sustained.

50.45. Sacroilitis

a. Injection of joint with a local anesthetic and steroid, up to four (4) times over a six (6) month period.

50.46. Piriformis Syndrome

a. Injection of muscle with a local anesthetic and/or steroid, in conjunction with physical medicine. No more than four (4) injections over a six (6) month period.

50.47. Post Laminectomy Syndrome/ Adhesive Arachnoiditis/ Spinal Stenosis/ Failed Fusion/ Intractable Radiculopathy/ Coccydynia.

a. Lumbar or caudal epidural steroids, up to four (4) injections over six (6) months.

b. Spinal cord stimulation as per Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, guidelines;

c. Intrathecal opioids as per Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, guidelines;

d. Trigger point injections, no more than six (6) points or no more than six (6) occasions in three (3) months.

50.48. Myofacial pain

a. Trigger points no more than six (6) points or no more than six (6) occasions in three (3) months.

Lower Extremity:

50.49. Lumbar radiculopathy

a. Lumbar epidural steroids, up to 4 injections over a 6 month period, in conjunction with physical medicine, if surgery in the opinion of the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, is not a medically viable option or if surgery has been attempted and failed to provide relief. If this needs to be repeated more than twice in 1 year or 4 cycles , a nurse case manager may be assigned to the claim. Authorization for continued treatment is at the sole discretion of the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable.

b. Documented interval improvement.

c. Spinal cord stimulation as approved by the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable.

50.50. Complex Regional Pain Syndrome (Reflex Sympathetic Dystrophy)

a. Referral to specialist immediately upon diagnosis.

b. Lumbar sympathetic plexus block, up to 12 times over a 3 month period;

c. Lumbar epidural infusion with analgesic agents, in conjunction with physical medicine, for up to 4 weeks;

d. Bier block, up to 6 injections over a 3 month period;

e. Spinal cord stimulation as approved by the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable.

50.51. Phantom Limb Pain/ Stump Pain

a. Lumbar sympathetic plexus block, up to 6 injections over a 3 month period.

b. Lumbar epidural infusion with analgesic agents, in conjunction with physical medicine therapy, for up to 4 weeks

c. Spinal cord stimulation as approved by the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable.

50.52. Peripheral Nerve Injury, including saphenouse, femoral or sciatic nerves

a. Nerve block, up to 6 injections over a 3 month period;

b. Bier block, up to 6 injections over a 3 month period;

c. Lumbar epidural infusion with analgesic agents, in conjunction with physical medicine, for up to 4 weeks;

d. Spinal cord stimulation as approved by the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable.

50.53. Greater Trochanteric Bursitis

a. Up to 3 injections with a local anesthetic and a steroid over a 3 month period.

50.54. Meralgia Paraesthetica

a. Injection of lateral femoral cutaneous nerve with a local anesthetic agent, up to 6 injections over a 3 month period.

50.55. Myofascial Pain

a. Trigger point injections, no more than 6 points or no more than 6 occasions in 3 months.

50.56. Other Causes Of Extremity Pain

a. Treatment will be authorized by the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, in it's sole discretion, on a case by case basis.

Cancer Pain:

Injury related causality must be established prior to authorization for pain management. A nurse case manager may be assigned to claims involving treatment of cancer pain. Unlike treatment for other types of pain, intrathecal opioids for treatment of cancer pain will not require psychiatric evaluation or a second opinion.

50.57. Long-Term Opioid Use: the use of long-term oral, rectal, or transdermal opioid therapy in the non-malignant injured worker is complex and should only be considered in selected injured workers, including, but not limited to, injured workers with diagnoses of failed back surgery syndrome, Complex Regional Pain Syndrome (Reflex Sympathetic Dystrophy), inoperable spinal lesions and spinal stenosis, or plexopathies. Other diagnoses will be considered by a case by case basis, but only as a treatment option of last resort. The following factors are to be addressed in writing in any report recommending the use of long-term opioid therapy:

a. If low dose opioid therapy has not provided at least partial analgesia, then long-term opioid therapy is not an option.

b. The goal of long-term opioid therapy is not complete analgesia. The efficacy of long term opioid therapy is measured by improvement in the injured worker's social and physical function.

c. This therapy should be considered only after all other reasonable attempts at analgesia have failed. Opioid therapy should never be a first line treatment.

d. A history of substance abuse in the injured worker or his or her family (alcohol or other drugs), even if remote, should be regarded as a relative contraindication. If a history of substance abuse is obtained and the choice to long-term, opioid therapy is made despite such history, an appropriate consultation and plan to prevent relapse must be in place before prescribing of opioids.

e. Pregnant injured workers are not candidates for long-term opioid therapy. Female injured workers of child-bearing age are to be advised of the risks to a fetus should pregnancy occur during opioid therapy.

50.58. If the decision is made to initiate long-term opioid therapy, the following must be part of the program:

a. Psychiatric - A psychiatric evaluation of the injured worker for psychiatric disorders and potential for substance abuse must precede the decision to carry out long-term opioid therapy, and a copy of the evaluation must be submitted with the request to initiate opioid therapy.

b. A written contract between the injured worker and the pain management specialist must be established at the onset of the long-term drug therapy. The injured worker must agree that (1) a single practitioner will be responsible for prescribing all medication for pain control; (2) the injured worker will not obtain prescriptions from providers other than the pain management specialist; (3) after an initial six month period of initial dose titration, only one dose escalation per three month period will be allowed; and (4) the injured worker will not consume alcohol or other medications except as approved by the pain management specialist. Any material violation discovered may cause immediate drug tapering and discontinuation of opioid maintenance therapy.

c. Initial long-term opioid therapy must be prescribed by a pain management specialist; once therapy has reached the "steady dose" level, the attending physician may resume medical management;

d. The injured worker will be monitored by a nurse case manager during the period when a "steady dose" is being established; the pain management specialist or the attending physician must reevaluate the injured worker every 60-90 days after the "steady dose" has been reached.

e. Injured workers must give informed consent before long-term opioid therapy is initiated; consent must include recognition of the risks of psychological dependence, cognitive impairment and long-term physical side-effects.

f. In order for long-term opioid therapy to continue, there must be documentation of improvement in the social and physical functions, as assessed and documented through home visits by a nurse case manager, written documentation must be provided to the attending physician and pain management specialist. Specific assessment tools must be used such as interview of significant others, pain drawing comparisons, quality of life and social functioning checklist comparisons.

g. Reassessment by a pain management specialist selected by the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, will be done annually for injured workers maintained on opioids.

h. Every year, the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, must review the treatment plant to determine the appropriateness of care. The Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, may call for more frequent review if the use of narcotic medication increases.

i. Evidence of acquisition of opioids from other physicians or persons, uncontrolled increases in dose requirements, drug hoarding, abuse of alcohol or other drugs, conviction of a crime related to drug possession or trafficking, or other behaviors in violation of the narcotic contract should be followed by immediate drug tapering and discontinuation of opioid maintenance therapy.

50.59. Implantable Devices: Use of intrathecal pumps and spinal cord stimulators will only be authorized when other treatments of extremity, back or neck pain, such as pharmacological, physical, or psychological therapy, have failed.

a. The procedure is undertaken only after physical and psychiatric or psychological screening. Psychological or psychiatric clearance will be performed to rule out any untreated psychiatric or behavioral problems and to enhance the efficacy of the device.

b. In the absence of a documented physiological problem, authorization for implantable pain control devices is at the discretion of the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable.

c. An untreated substance abuse problem prior to implementation of the proposed device will be sufficient reason to deny the request for the implantable device, notwithstanding other physical or psychological criteria.

d. An implantable device will not be authorized until a second opinion is given by a physician with credentials to implant similar devices. The second opinion may be based upon a review of the injured worker's file, or by an independent medical evaluation; either evaluation must be documented in writing. The referral of the injured worker or claim file for the second opinion must be arranged through the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable,.

50.60. Procedure Guides for Implantable Devices.

a. Implementation of devices will be authorized only at facilities which meet the following criteria:

(1) a physician trained in residency of by the "hands-on" continuing medical training will perform the procedure;

(2) all technical support, computers, and ancillary personnel, and a "stand-by" surgical specialist deemed necessary for the specific case must be in place before the procedure begins.

b. The implanting physician will be responsible for all management of the implantable device until such time that another physician credentialed in the management of like devices accepts the injured worker.

c. The necessary "in-home" support must be authorized by the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, and scheduled prior to implantation of the device.

d. Both intrathecal pumps and dorsal column stimulators must have a successful trial period before the permanent device is placed. The trial period for the pump will be no less than two days. The trial period for the stimulator will be no less that three days as an outpatient. There must be at least a 50% reduction in subjective pain rating and objective improvement in ability to engage in functional activities.

50.61. Contraindications for Implantable Devices: The following are contraindications for an implantation:

a. Allergies or hypersensitivity to the drug being used;

b. Life expectancy of less that three (3) months;

c. Body size is insufficient to support weight and bulk of the device;

d. Less than 50% relief is seen with trial stimulation or intrathecal device;

e. The injured worker does not perceive the trial implantation as pleasant, or side effects are intolerable;

f. The injured worker has an active coagulopathy;

g. The injured worker has a localized or disseminated infection;

h. The injured worker has a demand cardiac pacer or may need one relatively soon (for stimulator only);

i. The injured worker has an untreated substance abuse problem;

j. A significant psychological or behavioral contraindication has been identified;

k. The physician requesting the procedure is not adequately trained or experienced in the procedure;

l. Appropriate surgical coverage necessary to handle any complications is not available before beginning the procedure.

50.62. Myeloscopy in Chronic Pain Management - Myeloscopy procedures are to be reviewed on a case by case basis by the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, before authorization can be considered.

W. Va. Code R. § 85-20-50