2. 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.
3. 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.
4. 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.
5. 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.
6. 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).
7. 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.
8. 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.
9. 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.
10. 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
Why is he
smiling?
The Golden
Ticket: A new
Workers’
Comp patient.
11. 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.
12. 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.
13. 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.
14. 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.
15. 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.
16. 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.
17. 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
18. 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.
19. 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
