New York Issues New Workers Compensation Medical Guidelines
Roy Franco
November 18, 2010

By Alvena Ferreira, RN, CCM, CNLCP, MSCC and Katie A. Fox, MSCC

Effective December 1, 2010, the New York State Worker’s Compensation Board will implement medical treatment guidelines for injuries to the neck, mid and low back, shoulder, and knee. The guideline documents state that these were developed in part from the State of Colorado’s guidelines and ACOEM guidelines. The new guidelines put an emphasis on treatment that is directed to improve function, in order to achieve a return to work. In general, medical treatment that does not improve function is not recommended to be continued or repeated.

Per the WCB of NY:

“Use of the Guidelines will be mandatory for treatment rendered to the mid and low back, the knee, the shoulder and the neck for dates of service on or after December 1, 2010, regardless of the date of injury.”

Note that that these new guidelines apply to ALL WC cases, regardless of when the injury occurred! This means that these guidelines, when applicable, can be used as future care guidelines for New York WCMSA’s for shoulder, knee, neck, and mid/low back. (However, a copy of the state-specific guidelines should be submitted with the WCMSA, per Medicare’s instructions on state law considerations—see item #14.)

Several questions regarding the guidelines are found in the FAQ section of the NY WC website, where it specifically confirms, among other things, that the guidelines are mandatory under the law, and that the law applies to future care on old cases:

  • “Medical providers are expected to become familiar with the Guidelines and render treatment that is consistent with the Guidelines. When completing special Guideline forms, the medical provider should include the Guideline codes for each requested test or treatment (each test or treatment is assigned a specific series of numbers and letters in the Guidelines).”
  • “The regulations require insurance carriers to incorporate the Medical Treatment Guidelines into their policies, procedures, and practices and report their compliance to the Workers’ Compensation Board. The regulations require that insurers must pay providers for services rendered in accordance with the Guidelines.”
  •   “Existing cases will not have the full documentation on objective functional improvement, therefore medical providers and carriers must follow the general principles and the Treatment Guidelines as if it is a new case. For example, an injured worker has been receiving chiropractic treatment 2 times per month for over a year prior to December 1, 2010. As of December 1, 2010, the Medical Treatment Guidelines apply, therefore the injured worker must be evaluated at the end of a 3 week period to determine if there is continuing objective functional improvement. If the injured worker shows no objective functional improvement, additional chiropractic treatment would not be consistent with the Medical Treatment Guidelines.”

So what do these guidelines have in them that might impact a New York WCMSA? Here are some tidbits found the neck and mid/low back guidelines, but that there are many more guidelines in the actual documents that should be reviewed when completing a NY WCMSA:

  • The selective serotonin reuptake inhibitors (e.g., paroxetine, as well as bupropion and trazodone) are not recommended for treatment of chronic neck or chronic mid/low back pain. (They may be recommended for treatment of depression however.)
  • Aquatic therapy is not recommended for the neck, and limited to 6 weeks for the mid/low back.
  • Physical therapy has specified limitations for some modalities for neck and mid/low back.
  • Acupuncture: limited to 10 treatments for the neck and 12 treatments for the mid/low back. This appears to be a lifetime limitation per injury.
  • Manipulation: Maximum Duration: 3 months for neck and mid/low back. Extended durations of care beyond what is considered “maximum” may be necessary in cases of re-injury, interrupted continuity of care, exacerbation of symptoms, and in those patients with comorbidities. There is no efficacy for chronic treatment (manipulation several times a month for years) and chronic treatment is not recommended.
  • Epidural steroid and facet injections: limit of 3 per year for neck and mid/low back, and use only if effective.
  • Electrical therapy: TENS is allowed for the neck and for chronic (but not acute) mid/low back pain. For the mid/low back, other electrical treatment devices are not recommended, including PENS, microcurrent, H-wave, or interferential.

We suspect other states will follow the Colorado Guidelines and do as NY has done in rolling out Guidelines that structure the care for specific injuries. Franco Signor is ready to implement these new standards for WC cases and will provide the most reasonable and defensible MSA pricing. We are excited to see that states are moving toward more comprehensive treatment guidelines and feel that the stage is being set for improvement in the pricing of WCMSAs.