Rule 4123-6-31.1 | Supportive care.
This rule governs the identification and medical management of claims necessitating supportive care, including medical treatment reimbursement authorization. The objective is to ensure the timely and efficient provision of medically necessary and appropriate treatment reasonably related to the allowed conditions, in order to maintain or improve the injured worker's level of function, minimize or prevent regression or relapse, effectively manage symptoms, minimize disease or impairment progression, provide continuity of care, and minimize reliance on medication treatment.
(A) As used in this rule, "supportive care" means care that is medically necessary and that cannot be administered or performed by the injured worker independently and is needed to maintain therapeutic benefit, prevent or treat exacerbations, maintain function, or return to baseline function.
(B) A claim necessitating supportive care is a claim in which the injured worker has reached a plateau in recovery and which requires some level of ongoing care or medical treatment.
Such claims can be manifested by reduced function due to ongoing impairment, pain, or distress related to the allowed condition which diminishes quality of life, mobility, the ability to perform activities of daily living (ADLs), or work activity.
(C) The MCO shall evaluate the request for supportive care services through a review of the medical documentation in the file which must include the following applicable information:
(1) A comprehensive history and physical exam by the physician of record or treating physician that includes:
(a) The nature of the reported symptoms of the allowed conditions, their onset, duration, exacerbations, and any alleviating or aggravating circumstances;
(b) Objective findings of recent examinations;
(c) Report of current level of functioning using validated instruments and tools to assess life function and disruption of function due to the allowed conditions and the expected impact of the proposed plan of care on the current limitations caused by the allowed conditions;
(d) Prior treatment and response to treatment, including the results of any withdrawal of treatment; and
(e) Confounding factors, if any, affecting treatment plan decision-making.
(2) Clinical rationale for the treatment being requested;
(3) A treatment plan that includes:
(a) A description of the interventions requested, including proposed frequency and duration of treatment;
(b) Lifestyle modifications, if appropriate;
(c) A description of a home exercise program, if appropriate; and
(d) Specific goals to be achieved by the treatment being requested.
(D) The MCO shall consider the following while reviewing the medical documentation and determining if the claim necessitates supportive care:
(1) The allowed conditions;
(2) Changes in the injured worker's medical condition, which have occurred over the course of care, if any, including medication utilization, and physical and/or psychological function;
(3) Improvement or regression in function compared to baseline;
(4) Any confounding factors which may have impeded or aggravated the injured worker's progress; and
(5) Prior treatment and response to treatment, including the results of any withdrawal of treatment.
(E) The MCO shall, when approving or denying a request for supportive care, consider and document:
(1) Prior industrial commission decisions relating to prior requests for the same treatments;
(2) Any new or updated circumstances or information which support a different decision than the prior decision(s) of the industrial commission;
(3) Consistency or lack thereof of the current treatment reimbursement request with previously authorized requests; and
(4) Denial of any request for supportive, non-surgical care when a request for the same treatment has previously been granted by the industrial commission must be supported by documentation as to how the injured worker's current circumstances, which could include any new or updated information, differ from those present or presented when the industrial commission issued its order.
(F) Frequency and duration of medical treatment reimbursement requests for supportive care meeting the criteria outlined in this rule shall be approved regardless of whether they exceed treatment guidelines adopted by the bureau pursuant to rule 4123-6-16.1 of the Administrative Code.
Last updated February 3, 2025 at 8:36 AM
Supplemental Information