Effective January 1, 2018, the Ohio Bureau of Workers’ Compensation implemented new guidelines for the approval of lumbar fusion surgeries. These guidelines focus, not only on the request itself for the lumbar fusion surgery, but also whether other necessary means of treatment have been exhausted prior to undertaking lumbar fusion surgery. These guidelines implemented by the Bureau are applicable to both state fund and self-insured employers.
The new guidelines also address care and treatment of the claimant AFTER the approved surgery. The guidelines require BOTH the physician of record AND the operating surgeon to follow the claimant after the surgery until the claimant has reached MMI. For the first six months after the fusion surgery the claimant MUST be seen by BOTH the physician of record AND the surgeon at least every two months. During this initial six month post-operative period the doctors are to determine the following: (1) the fusion status; (2) the pain and functional status; (3) the status of MMI; (4) the residual level of functional capacity; and (5) the appropriateness of vocational rehabilitation. For the period of six-months to one-year after the fusion surgery and if the claimant continues to experience significant functional impairment then the following actions are recommended: (1) a pain and functional status (repeat VAS / pain diagram / Oswestry); (2) repeat baseline orthopedic exam / neurological exam; (3) repeat the behavioral health assessment; (4) revisit appropriate diagnostic imaging; and/or (5) coordinate with the self-insured employer / MCO to develop a plan of care / return to functional status.
The attached guide is meant to assist in evaluating whether a claimant and his/her physicians have undertaken and complied with all of the necessary requirements under O.A.C. § 4123-6-32. The attached guide is only meant to be used in assessing whether a claimant has met all of the required criteria under the new lumbar fusion surgery Code section, and should be used in conjunction with an independent medical review regarding whether a claimant’s request for lumbar fusion surgery is appropriate for the allowed conditions in the claim. Should you have any additional questions or concerns, please do not hesitate to contact a member of the Reminger Workers’ Compensation Practice Group.