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a dentist or chiropractor, respectively.
(5) The requestor or injured employee may appeal the
denial of a reconsideration request regarding an adverse determination
by filing a dispute in accordance with Labor Code §413.031 and
related division rules.
(6) A request for preauthorization for the same health
care shall only be resubmitted when the requestor provides objective
clinical documentation to support a substantial change in the injured
employee's medical condition or that demonstrates that the injured
employee has met clinical prerequisites for the requested health care
that had not been previously met before submission of the previous
request. The insurance carrier shall review the documentation and
determine if any substantial change in the injured employee's medical
condition has occurred or if all necessary clinical prerequisites
have been met. A frivolous resubmission of a preauthorization request
for the same health care constitutes an administrative violation.
(p) Non-emergency health care requiring preauthorization
includes:
(1) inpatient hospital admissions, including the principal
scheduled procedure(s) and the length of stay;
(2) outpatient surgical or ambulatory surgical services
as defined in subsection (a) of this section;
(3) spinal surgery;
(4) all work hardening or work conditioning services;
(5) physical and occupational therapy services, which
includes those services listed in the Healthcare Common Procedure
Coding System (HCPCS) at the following levels:
(A) Level I code range for Physical Medicine and Rehabilitation,
but limited to:
(i) Modalities, both supervised and constant attendance;
(ii) Therapeutic procedures, excluding work hardening
and work conditioning;
(iii) Orthotics/Prosthetics Management;
(iv) Other procedures, limited to the unlisted physical
medicine and rehabilitation procedure code; and
(B) Level II temporary code(s) for physical and occupational
therapy services provided in a home setting;
(C) except for the first six visits of physical or
occupational therapy following the evaluation when such treatment
is rendered within the first two weeks immediately following:
(i) the date of injury; or
(ii) a surgical intervention previously preauthorized
by the insurance carrier;
(6) any investigational or experimental service or
device for which there is early, developing scientific or clinical
evidence demonstrating the potential efficacy of the treatment, service,
or device but that is not yet broadly accepted as the prevailing standard
of care;
(7) all psychological testing and psychotherapy, repeat
interviews, and biofeedback, except when any service is part of a
preauthorized return-to-work rehabilitation program;
(8) unless otherwise specified in this subsection,
a repeat individual diagnostic study:
(A) with a reimbursement rate of greater than $350
as established in the current Medical Fee Guideline; or
(B) without a reimbursement rate established in the
current Medical Fee Guideline;
(9) all durable medical equipment (DME) in excess of
$500 billed charges per item (either purchase or expected cumulative
rental);
(10) chronic pain management/interdisciplinary pain
rehabilitation;
(11) drugs not included in the applicable division
formulary;
(12) treatments and services that exceed or are not
addressed by the commissioner's adopted treatment guidelines or protocols
and are not contained in a treatment plan preauthorized by the insurance
carrier. This requirement does not apply to drugs prescribed for claims
under §§134.506, 134.530 or 134.540 of this title (relating
to Pharmaceutical Benefits);
(13) required treatment plans; and
(14) any treatment for an injury or diagnosis that
is not accepted by the insurance carrier under Labor Code §408.0042
and §126.14 of this title (relating to Treating Doctor Examination
to Define the Compensable Injury).
(q) The health care requiring concurrent utilization
review for an extension for previously approved services includes:
(1) inpatient length of stay;
(2) all work hardening or work conditioning services;
(3) physical and occupational therapy services as referenced
in subsection (p)(5) of this section;
(4) investigational or experimental services or use
of devices;
(5) chronic pain management/interdisciplinary pain
rehabilitation; and
(6) required treatment plans.
(r) The requestor and insurance carrier may voluntarily
discuss health care that does not require preauthorization or concurrent
utilization review under subsections (p) and (q) of this section respectively.
(1) Denial of a request for voluntary certification
is not subject to dispute resolution for prospective review of medical
necessity.
(2) The insurance carrier may certify health care requested.
The carrier and requestor shall document the agreement. Health care
provided as a result of the agreement is not subject to retrospective
utilization review of medical necessity.
(3) If there is no agreement between the insurance
carrier and requestor, health care provided is subject to retrospective
utilization review of medical necessity.
(s) An increase or decrease in review and preauthorization
controls may be applied to individual doctors or individual workers'
compensation claims by the division in accordance with Labor Code §408.0231(b)(4)
and other sections of this title.
(t) The insurance carrier shall maintain accurate records
to reflect information regarding requests for preauthorization, or
concurrent utilization review approval or adverse determination decisions,
and appeals, including requests for reconsideration and requests for
medical dispute resolution, if any. The insurance carrier shall also
maintain accurate records to reflect information regarding requests
for voluntary certification approval/denial decisions. Upon request
of the division, the insurance carrier shall submit such information
in the form and manner prescribed by the division.
(u) For the purposes of this section, all utilization
review must be performed by an insurance carrier that is registered
with, or a utilization review agent that is certified by, the Texas
Department of Insurance to perform utilization review in accordance
with Insurance Code, Chapter 4201 and Chapter 19 of this title (relating
to Agents' Licensing). Additionally, all utilization review agents
or registered insurance carriers who perform utilization review under
this section must comply with Labor Code §504.055 and any other
provisions of Chapter 19, Subchapter U of this title (relating to
Utilization Reviews for Health Care Provided under Workers' Compensation
Insurance Coverage) that relate to the expedited provision of medical
benefits to first responders employed by political subdivisions who
sustain a serious bodily injury in course and scope of employment.
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| Source Note: The provisions of this §134.600 adopted to be effective December 23, 1991, 16 TexReg 7099; amended to be effective April 1, 1997, 22 TexReg 1317; amended to be effective January 1, 2002, 26 TexReg 9874; amended to be effective January 1, 2003, 27 TexReg 12359; amended to be effective March 14, 2004, 29 TexReg 2349; amended to be effective May 2, 2006, 31 TexReg 3566; amended to be effective July 1, 2012, 37 TexReg 2420; amended to be effective March 30, 2014, 39 TexReg 2102; amended to beeffective November 1, 2018, 43 TexReg 7174 |
