by The Bainbridge Firm, LLC | Feb 11, 2019 | Workers' Compensation
A tight, burning and stabbing sensation. Muscles spasms and tingling. The feeling of being electrocuted in the same spot repeatedly. Back pain comes in many forms. Millions of people experience the agony of back pain and while the pain is often bearable at first, bearable doesn’t cut it forever. For some people, surgery might feel like the only option.
Statistics and Background Information
According to the Bureau of Workers’ compensation, lumbar (lower back) pain is among the most common injuries suffered by Ohio workers each year.1 Like back pain, there are many different types of back surgeries, one if which is called spinal fusion surgery. Spinal fusion surgery involves connecting, or fusing, vertebrae together to eliminate movement thought to be the cause of pain and prevent the surrounding nerves, muscles, and ligaments from stretching. The theory behind spinal fusion surgery is that if painful vertebrae do not move, they should not hurt.2While this may sounds good in theory but in reality, not everyone has the best outcome with this type of back surgery.
Approximately 77% of spinal fusion patients do not return to work within two years after their surgery.3Studies have shown that not only do fusion surgeries decrease the likelihood that a patient will return to work, but fusions often lead to considerably worse outcomes for patients, including chronic opioid dependence, higher rates of failed back syndrome, increased disability, and the need for additional surgery, and new psychological conditions.4
Poor outcomes are not the only concern with lumbar fusion surgeries. Many people with low back pain are prescribed opioids during the course of their treatment, increasing their risk for opioid dependence. Prescription opioids, such as codeine, morphine, oxycodone, hydrocodone, and hydromorphone, are routinely prescribed after surgeries to help relieve pain while patients heal. Most people are able to adequately manage pain with over-the-counter pain killers after the initial few weeks of recovery from surgery. But what happens when surgery is not successful? For many people, the answer has been long-term use of prescription opioids to manage the pain. Unfortunately, the prolonged use of these drugs can lead to opioid dependency and cause more problems than the initial back pain.5
Ohio has experienced high rates of opioid dependence statewide. To help combat the overuse of prescription opioids, the Bureau of Workers’ compensation implemented a new rule addressing reimbursement for lumbar fusion surgeries in workers’ compensation claims.
Ohio Administrative Code 4123-6-32
The new rule, Ohio Administrative Code 4123-6-326, became effective on January 1, 2018. This new rule has four major parts and applies only to injured workers seeking a lumbar fusion surgery through workers’ compensation.
Under first part of this new rule, lumbar fusion surgeries will not be considered for reimbursement unless an injured worker has had at least 60 days of conservative treatment, such as physical therapy, rest, and chiropractic care. The conservative treatment must emphasize physical reconditioning and, when possible, include avoidance of prescription opioids. The conservative treatment requirement can only be waived in limited circumstances and with prior approval by the employer’s Managed Care Organization (MCO).
The rule also requires a surgeon to personally evaluate an injured worker on at least two occasions before requesting authorization for lumbar fusion surgery. In addition, injured workers must also have a comprehensive evaluation, coordinated by the treating physician and the operating surgeon. This comprehensive evaluation must include documentation of several factors, including, but not limited to, the use of specific evaluation tools, orthopedic/neurological examination findings, diagnostic test results, and opportunities for vocational rehabilitation, and a review of current and previous medications.
The second part of the rule specifically addresses authorization for lumbar fusion surgery for injured workers who do not have a prior history of lumbar surgery. The third part of the rule outlines requirements for authorization when an injured worker does have a prior history of lumbar surgery. These sections detail the criteria to be considered in light of an injured worker’s individual situation.
The last part of the rule addresses lumbar fusion after-care and requires both the treating physician and the surgeon to follow injured workers until they have reached maximum medical improvement for their lumbar conditions. This part of the rule also outlines guidelines for treatment during the first six months after surgery and recommended actions when an injured worker continues to experience significant impairments six to twelve months after surgery.
With this new lumbar fusion rule, the BWC hopes to incorporate the best clinical practices for the use of lumbar fusion surgeries, ensure injured workers are aware of treatment options and the risks involved in lumbar fusions, promote the use of conservative treatment before lumbar fusion surgery is considered, and provide criteria to be considered when an injured workers’ condition either does not change or worsens with conservative care.
If you have questions or concerns about how this new rule may impact you, please contact our office.
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