9.1. The Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, will pay for health care services, durable medical and other goods and other supplies and medically related items as may be reasonably required. The Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, will only pay for those services or items that have a direct relationship to the work related injury or disease, as determined in the sole discretion of the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable.9.2. A medical coverage decision is a general policy decision to be made in the sole discretion of the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, to include or exclude a specific health care service or supply as a covered benefit. These decisions are made to insure quality of care and prompt treatment of workers. Medical coverage decisions include, but are not limited to, decisions on health care services and supplies rendered for the purpose of diagnosis, treatment or prognosis, such as: a. Ancillary services including, but not limited to, home health care services ambulatory services, specific rehabilitative modalities;d. Drugs, biologics, and other therapeutic modalities;e. Durable medical equipment;i. Inpatient hospital stays and associated charges9.3. The Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, with some exceptions, will use these nationally-accepted standardized code sets for reporting medical conditions and treatment and may adopt successor code sets without amendment to this rule: a. Common Procedure Terminology (CPT-4) codes (HCPCS Level I codes), for provider professional servicesb. Alpha-numeric codes (HCPCS Level II codes) for supplies, equipment and other medical servicesc. Local Codes (HCPCS Level III) for unique Workers'-Compensation-specific services (NOTE: Use of these non-standardized codes is limited as much as possible)d. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) for reporting diagnoses of work-related injuries and occupational illnessese. Diagnostic related groups (DRG for in-patient hospital services)f. Revenue codes for outpatient hospital based servicesg. National drug codes (NDC) for pharmaceuticals9.4. CPT-4 Codes (HCPCS Level I). The Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, will update its vendor bill processing system to accept many of the new codes that are implemented nationally on an annual basis. This coding system, which uses a five-digit numeric code and allows for a two-digit modifier, is used to report most professional services, including Evaluation and Management, surgical intervention, anesthesia services related to surgery, physical medicine and other professional services.
9.5. HCPCS Level II National Alpha-numeric Codes. The Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, will accept many of the codes developed by CMS for reporting those medical services and supplies not addressed by the CPT-4 code set. This coding system uses a five-digit alpha-numeric code, which consist of one alphabetic character (a letter between and including A and V), followed by four digits. The codes all begin with a single letter and are followed by four-digits. HCPCS codes also use modifiers, either two digits or two letters.
9.6. HCPCS Level III Local Codes. The Level III codes are assigned and maintained by individual carriers. Like the HCPCS II National Codes, these codes begin with a letter (W through Z) followed by four numeric digits. The most notable difference is that these codes are not common to all carriers. Since 1999, the Commission has been eliminating the use of Local Codes wherever possible; however, there are still some local codes utilized by the Commission for services not normally reported by Medicare carriers.
9.7. ICD-9-CM Diagnosis Codes. The Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, shall use the ICD-9-CM coding system to report injured worker conditions in work-related injuries and occupational illnesses. Standard coding conventions shall be followed in reporting diagnosis. Payment will be denied for diagnosis judged, in the sole discretion of the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, to not be causally related to the compensable injury.
9.8. Written descriptions of procedures alone will not be accepted. Billing may be submitted on the CMS-1500 (formerly, HCFA 1500) and the CMS-1450 (formerly, UB-92), or the most current forms utilized by the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable. Pharmacy charges should be submitted using the on-line Point-of-Sale system, but can also be reported on the Universal Claim Form, or the most current form utilized by the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable. Certain non-standard services unique to the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, require Service Invoice, Form WC-400, or the most current form(s) utilized by the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable.9.9. Pre-authorization. Written authorization must be obtained from the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, in advance for the procedures and services listed below, except in emergencies or where the condition of the patient, in the opinion of the medical vendor, is likely to be endangered by delay. Failure to comply with this rule will result in disapproval of the medical vendor's bill. The vendor shall not seek reimbursement from the injured worker if payment is denied under this provision. This rule does not apply in cases involving initial treatment. 9.10. The following services require prior review and authorization before services are rendered and reimbursement made: a. Inpatient hospitalizations subsequent to the Date of Injury (emergency admissions are reviewed on a retrospective basis);b. Transfers from one hospital to another hospital (emergencies do not require authorization);c. Reconstructive and restorative surgeries;e. Purchase of TENS unit above the amount of $50.00;f. Treatment/supplies used in excess of three (3) months for TENS units;g. Psychiatric treatment (does not include the initial psychiatric consultation);h. Physical Medicine treatment in excess of this Rule;i. Outpatient pain management procedures (epidural steroids, facet injections, etc.);j. Medication not normally used in injury treatment and medication not listed on the preferred drug list, if applicable;k. Medication - Controlled Substance (in excess of this Rule);l. Durable Medical Equipment in excess of $500.00;m. Brainstem evoked audiometry;n. Repeat diagnostic studies (Workers' Compensation no longer requires approval for the initial MRI, CAT scan, Myelogram, EMG, and Nerve Conduction Studies);o. Standard/analog hearing aids;p. Programmable/digital hearing aids;q. Replacement hearing aids;r. Repair of hearing aids over the price of $250.00;s. Hearing Aid batteries over the allowed quantity of 50 per 6 months;t. Telephone amplification devices;u. Hearing aid assistance products (V5299);v. Non-emergency ambulance transportation;w. Non-emergency air transportation;x. All vision services and items associated with vision;y. All physical and vocational rehabilitative services;aa. All oxygen equipment, supplies, and related services;bb. All nursing, nursing home, and personal care services;cc. Home or vehicle modifications;ee. Work conditioning; and9.11. Prior-authorization requests shall be made in writing or electronically to the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, for approval.9.12. Medical services not specified above do not require prior approval but will be reviewed retrospectively to determine medical necessity. Services provided on an emergency basis are also subject to retrospective review to validate that the service was truly an emergency, and to determine medical necessity and relationship to the compensable injury.9.13. Disposable/Non-reusable Supplies. The Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, will reimburse for supplies prescribed by the authorized physician for use by the injured worker in the home setting which are reasonably required, as determined in the sole discretion of the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable. Supplies include dressings, colostomy supplies, catheters, and other similar items. The injured worker's related diagnosis must be stated on the prescription form.
9.14. Durable Medical Equipment Exceptions. The following durable medical equipment require prior-authorization, although reimbursed at less than $500:
a. E0585 Nebulizer with compressor;b. E0607 Home blood glucose monitor;c. E0610 Pacemaker monitor;d. E0730 TENS, name brand;e. E0731 Garment for TENS/ neuro-muscular;f. E0745 Neuromuscular stimulator, electronic shock unit; andg. E0935 Passive motion exercise device.9.15. The Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, shall deny bills for services rendered in violation of these Rules. Injured workers may not be billed for services denied pursuant to this provision.9.16. Bills must be itemized on department or self-insurer forms or other forms which have been approved by the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable. Bills may also be transmitted electronically using Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, file format specifications. Providers using any of the electronic transfer options must follow Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, instructions for electronic billing.9.17. Bills must specify the date and type of service, the appropriate procedure code, the condition treated, and the charges for each service.9.18. Bills submitted to the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, must be completed to include the following: a. Injured worker's name and address;b. Injured worker's claim number;d. Referring doctor's name;e. Area of body treated, including ICD-9-CM code(s), identification of right or left, as appropriate;i. Appropriate code to report services provided (including CPT, DRG, NCD, revenue codes, etc.);j. Description of service;o. The name and address of the practitioner rendering the services and the provider account number assigned by the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable;q. Submission of supporting documentation required by the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable.9.19. Responsibility for the completeness and accuracy of the description of goods and/or services and charges billed rests with the provider rendering the good or service, regardless of who actually completes the bill form.9.20. Bills must be received within six (6) months of the date of service to be considered for payment. Injured workers cannot be billed for any invoice denied under this provision.9.21. The following supporting documentation is required to have been received by the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, before reimbursement for a service is made: a. Laboratory and pathology reports;f. Special diagnostic study reports; andg. Special or closing exam reports.9.22. Requirements for payment of fees. Fees for examination or treatment are approved only when made by the health care provider duly licensed to make such examination or to render such treatment, and then only when the medical vendor actually sees and examines the patient and actually renders or directly supervises such treatment.
9.23. Additional services and accommodations not reasonably required for treatment of the compensable injury but requested by the injured worker shall be the responsibility of the injured worker.9.24. Failure on the part of the health care provider or other person, firm or corporation to submit fee bills to the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, for services rendered within the statutory period prohibits collection thereof from the injured employee, the employer, private carrier, self-insured employer, Insurance Commissioner or the Commission, whichever is applicable.9.25. Payment for drugs or medicine. The Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, may approve payment for drugs or medicines furnished to the injured worker as part of routine treatment rendered by the medical vendor. If unusual treatment is necessary, or if drugs or medicines are to be used by the injured worker at his home in the absence of the medical vendor, payment for a reasonable quantity of such drugs or medicines may be approved. Application for such payment must be accompanied by a statement of the medical vendor setting forth the necessity and purpose of the use of such drugs or medicines.9.26. Use of appropriate codes to report services is required and up coding (reporting a higher level of service than can be substantiated or actually was performed) is prohibited. Reimbursement shall not be made for such billing and up coding may be considered evidence of abuse under W. Va. Code § 23-4-3c and evidence of fraud under W. Va. Code § 61-3-24g.9.27. Prosthetics and Orthotics. Upon receipt of the attending medical vendor's report, the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, may refer the injured worker to a medical vendor or a Rehabilitation Center for evaluation to determine the type of prosthesis most beneficial for the particular injured worker involved and whether the injured worker is in need of training in use of the prosthesis. Upon receipt of the medical recommendations, the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, shall authorize the fitting of the recommended prosthesis. Payment shall not be approved until the prosthesis is determined to be serviceable and satisfactory. The requirement for prior approval for prosthesis shall not apply when the attending medical vendor utilizes the procedure of immediate amputation prosthetic application.9.28. A durable medical equipment supplier is required to exercise due diligence to verify that equipment is in use, that supplies are needed, and that a valid request for supplies has been made. Due diligence requires, but is not limited to, a personal contact with the injured worker. Reimbursement shall be denied for failure to exercise this required due diligence and may be evidence of fraud or abuse under Chapters 23 and 61 of the West Virginia Code.