How the Ohio BWC is Getting Tough on Opioid Pain Medications and Lumbar Fusion Surgery

Pursuant to Ohio Administrative Code Section 4123-6-32, which became effective January 1, 2018, the BWC will not reimburse providers for lumbar fusion surgery unless the treating physician follows the BWC’s “best practices” for the procedure.

In addition to the requirement that Injured Workers undergo at least 60 days of conservative care before having a lumbar fusion, the new rule emphasizes the BWC’s ongoing campaign to limit the use opioid pain medications.

Specifically, pursuant to O.A.C. 4123-6-32(A), authorization for lumbar fusion surgery will only be considered where:

  1. The injured worker had at least 60 days of “conservative care for low back pain” with an emphasis on:
    1. Physical reconditioning, which may include
      1. Heat/rest/ice, anti-inflammatories, pain management, chiropractic treatment, physical therapy or injections;
    2. Avoidance of opioids; and
    3. “Avoidance of provider catastrophizing the explanation of lumbar MRI findings”.
  2. The provider must meet requirements regarding performing a comprehensive evaluation, diagnostic testing, discussion of opportunities for vocational rehabilitation, and medication review.
  3. The physician must also have the patient review and sign the document “What the BWC Wants You To Know About Lumbar Fusion Surgery”.

Self-Insured employers can rely upon these rules as the basis for refusing to authorize surgery if the procedures in place have not been followed.

The new rules also bring to mind another Ohio Administrative Code regulation with respect to the use of opioid pain medications that Ohio employers should be aware of. Ohio Administrative Code Section 4123-6-21.7 requires that, with some exceptions, in the “subacute phase of pain treatment” (pain lasting more than 6 but less than 12 weeks following the injury or following surgery), opioid prescribing or dose increases that do not result in a “clinically meaningful improvement in function” are not necessary or appropriate in a workers’ compensation claim.  The provisions still allow ongoing opioid prescriptions for the treatment of chronic pain.

These administrative rules can help employers steer claims to their most effective resolution by getting injured workers the effective treatment they need to avoid excessive pain medications and unnecessary surgical procedures and get back to work as quickly as possible. That is by far the best outcome for all parties in a workers’ compensation claim.

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