Washington’s Department Medical Network Providers Required to Follow Department Treatment Guidelines Only when “Medically Appropriate”
Much of the focus on the new laws and rules that will come about after this most recent legislative session has been on the Department’s Medical Provider Network and utilization reviews that are set to go into effect in the coming years. However, one of the many changes to the workers’ compensation system following the 2026 legislative session is already in place.
Previously, medical providers who are members of the Department’s Medical Provider Network were required to follow the Department’s “evidence-based coverage decisions and treatment guidelines, policies” and were expected to follow national treatment guidelines that are appropriate for their patients. Employers and third-party administrators could also utilize the Department’s treatment guidelines and policies in claim administration decisions with reasonable certainty and predictability.
Now, however, RCW 51.36.010(1)(b) permits medical providers within the Medical Provider Network to follow the Department’s treatment guidelines and coverage decisions “when medically appropriate.” This allows network providers to make exceptions if medical treatment they previously might not have been able to.
In response to this change, the Department insists its “evidence-based coverage decisions and treatment guidelines, policies” are already medically appropriate and are based on findings of the Industrial Insurance Medical Advisory Committee, the Industrial Insurance Chiropractic Advisory Committee, the Washington State Health Technology Clinical Committee, and the Washington State Pharmacy and Therapeutics Committee.
The term “medically appropriate” is not defined within this statute, but the Department recently provided some guidance as to when requests for procedures not covered by “evidence-based coverage decisions and treatment guidelines, policies” may be “medically appropriate” based on the following criteria:
- The requested service is safe and effective, and
- Relevant individual circumstances and characteristics of the worker are not addressed by existing Department policy and guidelines, the plan of care is consistent with the worker’s symptoms and diagnoses, and it is “at least” as beneficial as existing or available methods.
The Department also intends to evaluate treatment authorizations or requests that either do not align with or may be contrary to its policies and guidelines and workers will still have the right to dispute an employer’s treatment decision.
The impact of this change is yet to be seen, but employers’ ability to rely solely on the Department’s treatment guidelines and coverage policies when authorizing or denying treatment requests may be limited. Until more time has passed and we are able to see how the Department responds to treatment disputes based on “medically appropriate” treatment determinations by treating providers, it seems prudent for employers to provide a detailed explanation of why a treatment request is denied. This could include relying upon an IME report, prior chart notes by the same or other providers disagreeing with the treatment or offering alternative treatment options, or even citing the evidence-based medicine rationale behind the Department’s guideline or coverage decision.
For example, the Department’s treatment guidelines for spinal injections includes a link to the Washington State Health Technology Clinical Committee “Final Findings and Decision” and cites the clinical guidelines from organizations such as American Society for Interventional Pain Management, American Society of Anesthesiologists Task Force/American Society of Regional Anesthesia and Pain Management, and the U.S. Food and Drug Administration Safe Use Initiative to develop and support the treatment recommendations and guidelines this Findings and Decision established. Providing this level of detail a treatment authorization decision could prove to be a deciding factor regarding whether the Department agrees with an employer’s treatment decision.
Ultimately, the impact of this change to RCW 51.36.010(1)(b) will likely become clearer in the upcoming months. My colleagues and I are closely monitoring how events unfold and the Department’s response to treatment requests that differ or wholly depart from its policy and coverage decisions.
If you as an employer or third-party administrator are faced with a treatment request that a treating provider deems “medically appropriate” and are unsure how to proceed, please do not hesitate to reach out via email () or phone (503-412-3117) to discuss what options and responses are available and appropriate.
Posted by Christine Olson.
