New York Treatment Guidelines

Highlights

X-Ray Testing

Routine x-rays are not recommended for acute non-specific back pain. X-rays are recommended for acute back pain with red flags for fracture or serious systemic illness, sub-acute back pain that is not improving, or chronic back pain ( C.1.a.ii ).

X-rays are used as an option to rule out other possible conditions. If an MRI is used as imaging, plain x-rays may not be needed.(C.1.a.iii )

Frequency/Duration: Obtaining x-rays once is generally sufficient. For patients with chronic back pain, it may be reasonable to obtain a second set months or years subsequently to re-evaluate the patient’s condition, particularly if symptoms change.

Testing-MRI

An MRI is not recommended for acute back pain or acute radicular pain syndromes in the first 6 weeks, in the absence of red flags (C.1.b.i), such as progressive neurologic deficit(s), cauda equina syndrome, significant trauma with no improvement in atypical symptoms, a history of cancer, or atypical presentation.

An MRI could be necessary for chronic radicular pain lasting at least six weeks when the patient's symptoms are not improving, and the patient and the provider are willing to consider prompt surgery assuming the MRI confirms nerve root compression.

When an epidural steroid injection is being considered for temporary relief of acute or sub-acute radiculopathy, an MRI may be reasonable 3-4 weeks before the steroid injection.

Testing-CAT Scan

A CT scan may be used for acute or sub-acute radicular pain that has failed to improve within 4-6 weeks and the patient and provider are willing to consider epidural steroid injection or a surgical discectomy.

Useful in patients with an indication for MRI but who cannot undergo MRI due to contraindications such as implanted ferrous device or significant claustrophobia.

A routine CT scan is not recommended for acute, sub-acute or chronic non-specific back pain or radicular pain syndrome. 

Testing-EDS

EDS may be used where a CT scan or an MRI is equivocal and there are ongoing complaints of pain, weakness, numbness, and/or parasthesias that suggest neurological compromise (for example: leg symptoms consistent with radiculopathy, spinal stenosis, peripheral neuropathy, etc...).

EDS may be used where there is failure of suspected radicular pain to resolve or plateau after 4-6 weeks (to provide sufficient time to develop EMG abnormalities as well as time for conservative treatment to resolve problems), CT or MRI studies are equivocal and there is a suspicion by history and physical examination that a neurological condition other than radiculopathy may be present, instead of or in addition to radiculopathy.

Electrodiagnostic testing is not recommended with acute, sub-acute or chronic back pain without significant leg pain or numbness.

Testing-Not Recommended

• Standing or weight-bearing MRI. • Fluoroscopy for evaluation of acute, sub-acute, or chronic back pain. • Diagnostic ultrasound.• Videofluoroscopy. • Lumbar discography, whether performed alone or with imaging studies

such as MRI or CT. • Myeloscopy. • Thermography. • Surface Electromyography (Surface EMG).

Treatment-ESI

Epidural Steroid Injections may be used for acute or subacute radicular pain syndromes lasting at least 3 weeks, having been treated with NSAIDs without improvement or symptoms of spinal stenosis of 1-2 months, with prior treatment that has included NSAIDs and progressive exercise.

Maximum Duration: 3 injections may be performed in one year depending upon patient response (improved function and pain reduction).

ESI’s are not recommended for acute, subacute or chronic back pain in the absence of significant radicular symptoms or in individuals with back pain that predominates over leg pain.

Treatment-Medications

Narcotics have limited use for acute back pain with severe pain or a brief prescription for post-operative pain management. They should be prescribed with strict time, quantity, and duration guidelines and definitive cessation parameters.

Optimum duration: 3-7 days. Maximum duration: 2 weeks. Use beyond two weeks may be acceptable in appropriate non-acute cases and

should be documented and justified in the medical record based on diagnosis and/or invasive procedures. Under the proposed guidelines there will be mandatory testing and the carrier will be informed only if the claimant passes or fails the test. No other test information will be given and the employer can’t take disciplinary action based upon a failed test.

Treatment - Physical Therapy

Therapeutic exercise, where a therapist instructs the patient, may be appropriate for patients when there is a need to: reduce edema, improve muscle strength, improve connective tissue strength and integrity, increase bone density, promotion of circulation to enhance soft tissue healing, improve muscle recruitment, improve proprioception and coordination and increase range of motion.

Therapeutic exercises may include isoinertial, isotonic, isometric, and isokinetic types of exercises, with or without mechanical assistance or resistance.

Frequency: 3-5 times per week. Optimum duration: 4–8 weeks. Maximum duration: 8 weeks.

Treatment - Manipulation

Manipulation may be used as follows:For acute and subacute back pain. The use of manipulation must be tied to objective measures of improvement.Frequency: First four weeks: Up to 3 treatments per week as indicated by the severity of involvement.Next four weeks: Up to 2 treatments per week with reevaluation for evidence of functional improvement or need for further workup.Continuance depends upon functional improvement.Optimum duration: 8 – 12 weeks.Maximum duration: 3 months

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The Golden Ticket: A new

Workers’ Comp patient.

Treatment - Manipulation

Life Long unlimited

Treatment:Hell No!

An ongoing maintenance program of spinal manipulation (by a physician (MD/DO, chiropractor or physical therapist) may be indicated in certain situations, after the determination of MMI, when tied to maintenance of functional status.

Frequency: Maximum up to 10 visits/year, after the determination of MMI, according to objectively documented maintenance of functional status. No variance from the maximum frequency is permitted.

Treatment - Maintenance Program• Maintenance care is a course of treatment that may include PT, OT or spinal

manipulation, depending on the body parts involved. In certain circumstances, an ongoing maintenance care program may be indicated to maintain a patient's functional status if there has been a previously observed and documented (in the medical record) objective deterioration in functional status without the identified treatment.

• Criteria: The Claimant must reach MMI first then a provider must establish, with documentation in the medical record, that the previous treatment maintained functional status and that, without treatment, functional status deteriorated. The need for ongoing maintenance treatment must be evaluated periodically by progressively longer trials of therapeutic withdrawal of maintenance treatment. Within a year, and annually thereafter, a trial without the maintenance treatment should be instituted. If deterioration in functional ability is documented during the therapeutic withdrawal, reinstatement of the ongoing maintenance care program may be acceptable.

• There is a limit of 10 visits per year per body part when the criteria for the program are met. A variance for additional treatment during the remainder of the year is not permitted.

Treatment - Thermal Treatment

Thermal treatment may be used for acute pain, edema, hemorrhage, a need to increase pain threshold, reduce muscle spasms, and promote stretching and flexibility. Cold and heat packs may be used at home as an extension of therapy.

Frequency: 2-5 times per week. Optimum duration: 3 weeks as primary therapy or intermittently as an adjunct to other therapeutic procedures up to 2 months.

Treatment-TENS

TENS treatment may be used selectively in chronic back pain or chronic radicular pain syndrome as an adjunct for more efficacious treatment.

Must be used as an adjunct to active therapy such as graded aerobic and strengthening exercises. Minimal TENS unit parameters include pulse rate, pulse width, and amplitude modulation.

The use of TENS must be tied to consistent, measurable, functional improvement. A determination of the likelihood of chronicity is required prior to the provision of a home unit.Optimum duration: 2-3 sessions. Maximum duration: 3 sessions after which a home unit should be provided/purchased.

Treatment – Not Recommended

Electrical therapies: Inferential therapies. Percutaneous electrical nerve stimulation (PENS). Microcurrent electrical stimulation. Electrical nerve block. Electrical stimulation (unattended). Transcutaneous neurostimulator (TCNS). H-wave stimulation. High-voltage galvanic ontophoresis.Injection therapies: Intradiscal steroids. Chemonucleolysis (Chymopapain and Collagenase). Facet joint hyaluronic acid injections. Prolotherapy injections. Platelet rich plasma (PRP).Radio frequency neurotomy, neurotomy, and facet rhizotomy: Dorsal root ganglia radiofreqency lesioning. Intradiscal electrothermal therapy (IDET). Percutaneous intradiscal radio frequency thermocoagualtion (PIRFT).Passive therapy: Manipulation under anesthesia (MUA) and medication-assisted spinal manipulation. Diathermy. Low level laser therapy. Mechanical devices for administering massage. Myofascial release. Neuroflexotherapy. Reflexology. Traction. Acupuncture - Not recommended for acute, subacute and radicular pain. Vertebral axial decompression (VAX-D) and other decompressive devices. Kinesiotaping, Taping or Strapping - not recommended for acute, subacute or chronic pain.Biofeedback: Not recommended for patients with acute or subacute back pain.

Surgeries-Requiring Authorization

Surgical procedures of the mid and low back requiring pre-authorization include: Lumbar fusion.Non-invasive electrical bone growth stimulators (as an adjunct to spinal fusion therapy).Artificial disc replacement.Vertebroplasty.Kyphoplasty.

Objections to Payment for Treatment

The Carrier has 45 days in which to pay a bill or to object to payment. Objections are in three categories--legal liability objection for which the C-8.1 Part B is used, valuation for which the C-8.4 is used and failure to use the fee schedule for which a EOB letter is used.

1) EOB (a letter produced by the carrier/employer explaining their position)

This letter is only used if the doctor bills at his own rates and the carrier/employer responds by paying the proper N.Y. fee schedule rate. This EOB letter would be sent to the doctor and the Board.

2) C-8.1 (Board Form - Disputed Bill Issues) Is utilized for legal objections (decided by a law judge) that are not MTG issues and for four MTG reasons as follows:

Treatment provided was not based on correct application of the Guidelines.

Treatment deviates from the Guidelines without securing a Variance.

Treatment not consistent with the approved Variance

Variance denied without claimant timely requesting review or variance denied by Board Decision filed

Objections to Payment for Treatment

MTG Objections explained:

Treatment provided was not based on correct application of the Guidelines.

An example would be continuing physical therapy past the maximum allowed.

Dr failed to meet the criteria for ongoing maintenance (10 visits).

Treatment deviates from the Guidelines without securing a variance.

Medical Provider provided treatment outside the Guidelines without getting approval.

Treatment not consistent with the approved Variance.

Medical Provider did not act within the approved variance.

Variance denied without claimant timely requesting review or variance

denied by board decision filed.

Claimant failed to timely request review of denied variance.

Objections to Payment for Treatment

3) C-8.4 Board Form - Carrier's Refusal to Pay All (or a Portion) of a Medical Bill Due to Valuation Objection(s) (decided by the arbitration process).

The reasons for objecting that are not MTG issues:

Amount of Bill:

o Is excessive or not in accordance with pertinent NYS Medical Fee Schedule

o Has not been properly pro-rated or apportioned between medical providers

o Uses improper CPT codes

o Is not in accordance with Ground Rules limitations

Treatment:

o Is inappropriate

o Involves concurrent or overlapping services

o Is duplicative, excessive or rendered too frequently

o Involves unnecessary or excessive hospitalization

o Involves a medical provider treating outside scope of practice