Section 0800-02-25-.03 - TREATMENT GUIDELINES(1) Effective January 1, 2016, the Tennessee Bureau of Workers' Compensation adopts the current edition, and any future published updates, of the Work Loss Data Institute ODG Guidelines as published by the Work Loss Data Institute, the Chronic Pain Guidelines of the State of Tennessee, Department of Health, and any other related appendices to the above-referenced guidelines adopted by the Administrator.(2) Medical treatment provided by or at the direction of the authorized treating physician, or other healthcare provider, in accordance with the ODG Guidelines, Chronic Pain Guidelines of the State of Tennessee, Department of Health, and any other related appendices to the Guidelines adopted by the Administrator in effect at the date the treatment is recommended, listed in section (1) above is presumed to be reasonable and necessary. Any utilization review of treatment must apply the ODG Guidelines listed in section (1) above, in determining whether treatment is medically necessary. Any treatment that explicitly follows the treatment guidelines adopted by the administrator or is reasonably derived therefrom, including allowances for specific adjustments to treatment, shall have a presumption of medical necessity for utilization review purposes. This presumption shall be rebuttable only by clear and convincing evidence that the treatment erroneously applies the guidelines or that the treatment presents an unwarranted risk to the injured worker.(3) It is recognized that each individual clinical situation and patient is unique. The guidelines are not a standard or a mandate. Exceptions to and the proper application of the guidelines require judgment. The Utilization Review and prior approval/authorization procedures and timeframes remain in effect. See Utilization Review Rule 0800-02-06. A mechanism for the timely appeal for these exceptional situations is set forth in Rule 0800-02-06-.07 Appeals.(4) The employer shall not deny treatment based solely on the determination that the treatment falls outside of the guideline if such denial is not supported by documented evidence-based medicine.(a) If a provider makes a written request by fax or e-mail (and receives acknowledgement of receipt of the request) for authorization for a treatment at least 21 business days in advance of the anticipated date that treatment is to be delivered and has not been notified in writing or confirmed telephone call or confirmed fax at least 7 business days in advance of the date of the proposed treatment, it is presumed to be medically necessary, a covered service, and to be paid for by the employer.(b) If a provider makes a verbal request for authorization, the burden of proof for showing that authorization was granted by the employer rests with the provider.(5) The employer shall not be responsible for charges for medical treatment that is not in accord with the guidelines unless:(a) It was provided in a medical emergency,(b) It was authorized by the employer,(c) It was approved through the appeal process by the Bureau.(6) As the Work Loss Data Institute releases updated guidelines or other information pertinent to the interpretation or application of any such guidelines, the Medical Director, in consultation with the Medical Advisory Committee, shall review all such updates or other information, on a semi-annual or annual basis as deemed appropriate by the Medical Director, and report to the Administrator the impact, if any, of such updates on the continuing viability of the guidelines for use in Tennessee. The Administrator will include any such pertinent information and/or recommendations in the Bureau's annual report to the general assembly.(7) As of January 1, 2016, physicians and other providers dispensing drugs required to be reported in the Tennessee Controlled Substances Monitoring Database (CSMD) from their offices or clinics must report these medications in the Tennessee Controlled Substances Monitoring Database (CSMD) within one business day of the dispensing of those medications. These provisions are in accord with T.C.A. § 53-10-305, T.C.A. § 53-10-307 and T.C.A. § 53-10-310 as amended.Tenn. Comp. R. & Regs. 0800-02-25-.03
Original rule filed November 30, 2015; effective February 28, 2016. Amendments filed November 7, 2017; effective 2/5/2018.Authority: T.C.A. §§ 50-6-122, 50-6-124, 50-6-125, 50-6-126, and 50-6-233.