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Utilization Review Appeals and Pain Management

Best Practices for Handling Utilization Review Appeals Dr. Robert Snyder, Medical Director Dr. Jeff Hazlewood, Assistant Medical Director Melissa Sanders, Moderator. Utilization Review Appeals and Pain Management. Robert B. Snyder, M.D. Jeffrey E. Hazlewood , M.D. Suzy Douglas, R.N.

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Utilization Review Appeals and Pain Management

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  1. Best Practices for Handling Utilization Review AppealsDr. Robert Snyder, Medical DirectorDr. Jeff Hazlewood, Assistant Medical DirectorMelissa Sanders, Moderator

  2. Utilization Review Appeals and Pain Management • Robert B. Snyder, M.D. • Jeffrey E. Hazlewood, M.D. • Suzy Douglas, R.N. • Melissa Sanders, U/R Program Manager

  3. New Rules • May 4, 2014: $250 to file an appeal (charged to carrier) • Appeal Form: C35A Fee notice is on the web under latest news: http://www.tn.gov/labor-wfd/wcomp/news_updates.shtml

  4. OLD RULES Before a denial can be issued, all the information must be available. If there is missing or incomplete information, a request must be sent in writing for that information before the denial can be issued. See rule 800-02-06-06(5)(a) Text 208463 and your Questions to 22333

  5. What to Do(1) • Read the U/R review in its entirety. • Understand the denial. • Review and understand the guideline used to judge the request. Text 208463 and your Questions to 22333

  6. What to Do(2) • Review the records to be sure the request was accurate and complete. • Formulate a response to each point of the denial. • Document the response from the medical record. Text 208463 and your Questions to 22333

  7. What to Do(3) • Write a cover letter refuting the denial. • Complete the form. Text 208463 and your Questions to 22333

  8. What to Do(4) • Send all of the records that are pertinent, including all of the test results, and appeal letter. (May be longer or more than one year) Text 208463 and your Questions to 22333

  9. What to Expect • A confirmation of receipt • After all of the information has been received, a decision will be issued within 25 business days. Most decisions will be issued within 7 days. Text 208463 and your Questions to 22333

  10. Where to find it Forms: http://www.tn.gov/labor-wfd/mainforms.shtml Telephone Contacts: http://www.tn.gov/labor-wfd/wcomp/wc_contacts2.pdf Appeals information: 615-253-2374 http://www.tn.gov/labor-wfd/wcomp/news_updates.shtml Text 208463 and your Questions to 22333

  11. Pain Management Utilization Review Requests Text 208463 and your Questions to 22333

  12. Types of Requests • Injections • Spinal Scheduled (II-IV) Medications (opioids, benzodiazepines, Soma, sleep aids) • Cord Stimulators • Physical Therapy Text 208463 and your Questions to 22333

  13. Physical Therapy • Diagnosis and Chronicity of injury • Total # of PT visits already done • PT documentation of progress with: • Pain • Strength • ROM • Function • Reason more PT needed and why can’t be accomplished with HEP

  14. Opioids(1) • I’m looking for: • Dosages • Pain Levels (VAS) • Functional improvement (objective measures) • Opioid assessment tools, UDS results, pill counts • Objective basis • Failure of other treatment plans Text 208463 and your Questions to 22333

  15. Opioids(2) • Comorbid medical problems • History of addiction • Concurrent use of alcohol • Escalation over time especially without improvement in function Text 208463 and your Questions to 22333

  16. Other Scheduled Medications • Muscle Relaxers • Sleep Aides • Benzodiazepines Text 208463 and your Questions to 22333

  17. ESIsOther Injections(1) • Axial vs Lower extremity distribution of pain • Objective findings of radiculopathy or • True radicular pattern matching with imaging • Chronicity of pain and other pyscho-social factors • Previous responses—documentation is key; was medicine decreased/function improved with the injection? Text 208463 and your Questions to 22333

  18. ESIsOther Injections(2) • Are various injections being used in a shot-gun approach? • Are ESI’s ordered in series of 3? • Are multiple injections ordered same date? • Is the order just for “ESI” without level mentioned? Text 208463 and your Questions to 22333

  19. ESIsOther Injections(3) • Are various injections being used in a shot-gun approach? • Should facet injections/MNBB’s/rhizotomieshave at least some exam evidence of facet mediated pain? • Need documentation in records of good neurological and musculoskeletal exam Text 208463 and your Questions to 22333

  20. Spinal Cord Stimulators • Axial vs Lower extremity distribution of pain • Psychological factors—must have screening • Diagnoses • Failed Back Syndrome with radiculopathy • CRPS—at least some objective findings • Need objective findings, not just subjective pain complaints Text 208463 and your Questions to 22333

  21. Recommendations • Subscribe to the Official Disability Guidelines • (Used by 75% of U/R Companies) • Write a cover letter with a full explanation of reason for appeal • Better documentation in records of dermatomal distributions of pain, thorough neurological exams • Avoid repetitive EMR records; “personalize each visit” Text 208463 and your Questions to 22333

  22. July 1, 2014 New forms Filing Fee (as of May 4, 2014) Treatment guidelines (as of January 1, 2016) 1. Simplify and standardize interpretation. 2. Reduce the reason for a denial (and subsequent appeal). Text 208463 and your Questions to 22333

  23. Remember: Date of Injury on or after July 1, 2014 Not retroactive Causation Administrative Courts Maximum Medical Improvement Permanent Impairment Pain Guidelines Aggravation of pre-existing conditions Panel rules Text 208463 and your Questions to 22333

  24. Thank you Medical Unit: Robert Snyder, M.D: robert.b.snyder@tn.gov James Talmage, M.D james.talmage@tn.gov Jeffrey Hazlewood, M.D. Suzy Douglas: suzy.douglas@tn.gov Margaret Collier: margaret.collier@tn.gov Melissa Sanders: melissa.d.sanders@tn.gov Kelly Burns: kelly.burns@tn.gov Brooke Griffith: brooke.griffith@tn.gov Text 208463 and your Questions to 22333

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