Department of Labor & Industries Updates Medical Treatment Guidelines for Lumbar Spine Surgery
On September 21, 2021, the Washington Department of Labor & Industries published new treatment guidelines for lumbar spine surgery. For those unfamiliar, the Medical Treatment Guidelines are evidence-based review criteria that are developed and updated by the Office of the Medical Director in collaboration with practicing physicians in the relevant medical community. Healthcare providers treating injured workers in the State of Washington are expected to be familiar with the guidelines and follow the recommendations. The Department uses their treatment guidelines in their utilization review program to ensure injured workers are only receiving only proper and necessary medical care. The goals of the guidelines are to distinguish between clear-cut indications for procedures and those that are questionable; and to implement evidence-based treatment guidelines in a fair manner. Overall, the guidelines are a useful tool for medical providers and claim examiners to ensure that an injured worker’s treatment is reasonable and necessary.
The Department’s updated Treatment Guidelines for Lumbar Spine Surgery discusses lumbar decompression procedures, lumbar fusion procedures, sacroiliac joint fusions. Prior to this update, the most recent guidelines were updated 2016 and had only discussed recommendations for lumbar fusions. The new guidelines discuss all surgical procedures and include useful charts showing what types of objective findings should be identified and what prior treatment completed in order to consider the treatment reasonable and necessary. For example, the Department explains that lumbar fusions (which involve stabilization of the lumbar spine by fusing one or more vertebrae together), should only occur with moderate-to-severe spondylolisthesis, after prior decompression surgery at the same level has failed, a prior failed lumbar fusion with corresponding objective findings of instability, or after a recurrent disc herniation in certain situations. A fusion to treat recurrent disc herniations following more than two discectomies at the same level may be appropriate if the worker has greater than Grade-2 Spondylolisthesis, with two or more of the following: dermatomal sensory deficit on exam, motor deficit, positive dural-tension signs (i.e. straight leg test), asymmetric reflex changes, or acute denervation findings on EMG. The lumbar treatment guidelines mostly discuss positive indications for surgery, but they also identify relative contraindications for surgery and absolutely contraindications for surgery. If an injured worker has contraindications for surgery, the treating provider should provide justification for why surgery is necessary even when considering those contraindications.
As most employers know, an injured workers’ chances of successfully returning to work significantly drop following lumbar fusion. And, often times, a lumbar fusion is the second or third surgery performed on a claim that ultimately ends in total permanent disability. Accordingly, it is very important that self-insured employers ensure that recommended surgical treatment meet the criteria set forth in the Department’s Medical Treatment Guidelines for both less-invasive decompression surgeries and all lumbar or sacroiliac fusions. If you receive a request for authorization of a lumbar surgery and are unsure whether the surgery is appropriate, or the attending provider has not provided you with the necessary justification, you can schedule an IME to address whether the surgery is reasonable and necessary. My office will be happy to assist you evaluating the medical records and obtaining a qualified second opinion that sufficiently addresses the Department’s Medical Treatment Guidelines.
If you have any questions regarding the Department’s new Lumbar Spine Surgery Guidelines, please do not hesitate to give me a call at (503) 595-6105 or email me at .