Washington State HTCC Decisions: Is Additional Medical Support Required to Defend Treatment Denial?
I know what you are thinking: what is the HTCC?
In 2006, Washington State created the Health Technology Committee (HTCC) to make coverage decisions for selected health technologies. Governed by the Washington State Health Care Authority, the HTCC’s decisions are followed by state purchased health care programs including the Department of Labor and Industries. The Committee’s eleven members review available medical literature and hear from experts to determine if certain health technologies should be covered.
Since the HTCC hands down decisions approving or rejecting certain treatment and procedures, the Department will sometimes approve or deny treatment exclusively based on an HTCC finding. Claim administrators can be tempted to see these decisions as an easy win—but not so fast.
While the Department may deny treatment based on an HTCC decision, these determinations are still reviewable by the Board of Industrial Insurance Appeals (BIIA). The Washington Supreme Court addressed this scenario in Murray v. Dep’t of Labor & Indus. 192 Wash.2d 488 (2018).
In Murray, the worker sustained a work-related hip injury, and his provider requested authorization for surgery to address his related FAI syndrome. The Department denied the surgery because of an HTCC finding denying coverage for the particular FAI surgery. When issuing its treatment decision, the Department only based it on the HTCC finding; it did not provide an independent determination based on the claimant’s attending physician or independent medical examiner whether the procedure was medically necessary and proper.
Upon Review, the Washington Supreme Court determined that the Department of Labor and Industries, not the HTCC, is responsible for medical treatment coverage decisions. Therefore, HTCC decisions do not have preclusive effect and the Department’s medical coverage decisions are reviewable by the BIIA and the superior court.
The decision in Murray is important because it means that if the Department denies treatment based on an HTCC decision, the employer will still need to defend that decision with a medical opinion if it is appealed. If the employer relies on a Department decision citing only the HTCC findings, the worker need only present medical evidence that the proposed treatment is in fact medically necessary. If the employer fails to present its own medical evidence showing the requested treatment is not medically necessary, the Board will likely authorize the treatment.
While Department decisions based on HTCC findings may seem like an easy win, employers should be cautious of them. If the Department has an HTCC decision to rely on, it will often deny treatment without considering the claim-specific medical evidence before it. This can actually leave the employer in a worse position, because there is no additional medical reasoning supporting the denial. In such cases, employers should also obtain their own medial evidence supporting the decision. If they do not, it risks the Department decision being reversed.
Please do not hesitate to contact Nathan at 503-776-5426 or to discuss the HTCC and how to navigate related decisions at the Department and Board of Industrial Insurance Appeals.
Posted by Nathan McFadden.
