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OhioBWC - Basics: (Policy library) - File

Policy Name:

PSYCHIATRIC CONDITIONS

Policy #:

CP-16-01

Code/Rule Reference:

R.C. 4123.01 and 4123.53.

O.A.C.4123-3-08, 4123-3-09, 4123-3-16 and 4123-5-18.

BWC/IC Joint Resolutions R-03-1-01, R-92-1-1 and R-94-1-12.

Effective Date:

02/26/14

Approved:

Rick Percy, Chief of Operational Policy, Analytics and Compliance (Signature on file)

Origin:

Claims Policy

Supersedes:

07/15/13; 02/05/13

History:

New 02/05/13; Rev. 07/15/13; 02/26/14

Review date:

02/26/19

 

 

I. POLICY PURPOSE

 

The purpose of this policy is to ensure BWC appropriately allows psychiatric conditions in accordance with the law and rules.

 

II. APPLICABILITY

 

This policy applies to Field Operations, Medical Services and Legal Division staff.

 

III. DEFINITIONS

 

Forced sexual conduct:  for purposes of this policy and related procedure, means where the injured worker’s psychiatric conditions have arisen from sexual conduct in which the injured worker was forced by threat of physical harm to engage or participate.

 

Injury:  for purposes of this policy and related procedure, includes psychiatric conditions when the injured worker’s psychiatric conditions have arisen from an injury or occupational disease sustained by that injured worker, or where the injured worker’s psychiatric conditions have arisen from forced sexual conduct.

 

Sexual conduct:  for purposes of this policy and related procedure, means  vaginal intercourse between a male and female; anal intercourse, fellatio, and cunnilingus between persons regardless of gender; and, without privilege to do so, the insertion, however slight, of any part of the body or any instrument, apparatus, or other object into the vaginal or anal cavity of another. Penetration, however slight, is sufficient to complete vaginal or anal intercourse.

 

IV. POLICY

A.   General policy statements

1.    It is the policy of BWC to evaluate initial and additional allowance requests for a psychiatric condition(s) in a claim that arise from:

a.    An injury or occupational disease sustained by the injured worker when a compensable physical injury sustained by the claimant causes the mental condition.  Armstrong v. John R. Jurgensen Co., Slip Opinion No. 2013-Ohio-2237; or

b.    Forced sexual conduct.

2.    It is the policy of BWC that for recognition of a psychiatric condition(s) the request is accompanied by supporting medical documentation consisting of the following:

a.    The medical report is submitted by a:

i.      Licensed psychiatric specialist;

ii.     Clinical psychologist;

iii.    Licensed Professional Clinical Counselor (LPCC); or

iv.   Licensed Independent Social Worker (LISW).

b.    The medical report is detailed and includes the following:

i.      The specific psychiatric condition(s) diagnosis with narrative description and the appropriate diagnosis code;

ii.     Causation statement;

iii.    The psychiatric findings;

iv.   Detailed explanation of the causal relationship of the diagnosed psychiatric condition to the work-related injury or occupational disease;

v.    Information that is clearly reasoned and rationalized.

c.    The medical report verifies the psychiatric condition(s) arose from an injury or occupational disease sustained by the IW or forced sexual conduct.

d.    The medical report addresses each psychiatric condition(s) requested.

3.    It is the policy of BWC that a request for a psychiatric condition(s) will not be based on a medical report from an:

a.    Advanced Practice Registered Nurse (APRN), or

b.    Advanced Practice Nurse (APN).

4.    It is the policy of BWC that BWC may obtain a psychiatric independent medical examination or physician file review to provide a medical opinion on the following:

a.    The presence of a psychiatric condition in a claim as an initial determination or an additional allowance request;

b.    The necessity and appropriateness of psychiatric treatment;

c.    The extent of a psychiatric disability.

 

B.   Initial determination request for a psychiatric condition(s)

1.    BWC may receive an initial determination request for psychiatric condition(s) on a First Report of an Injury, Occupational Disease or Death (FROI-1) concurrent with the request for a physical injury or as a result of forced sexual conduct.

a.    An initial determination requesting a psychiatric condition(s) as a result of forced sexual conduct is treated the same as any other claim for an initial determination.

b.    A request for psychiatric condition(s) arising out of forced sexual conduct is the only instance where the law allows for the initial determination of psychiatric, emotional or stress claim absent a physical injury.

2.    It is the policy of BWC that an injured worker must sign and date the FROI-1 application requesting a psychiatric condition(s).

3.    BWC does not require an injured worker declaration statement for a psychiatric condition(s) filed for an initial determination request.

 

C.   Additional allowance request for a psychiatric condition(s)

1.    BWC must receive an additional allowance request for a psychiatric condition(s) on a Motion (C-86).

2.    For each requested psychiatric condition, BWC must receive a signed and dated declaration statement from the injured worker that says, “I am aware that this motion is being filed to request that the bureau or commission recognize my emotional problem, nervous condition, or psychiatric disability as being a result of the injury for which this claim is allowed.”

3.    BWC will not process requests for a psychiatric condition(s) recommended by a treating physician on a Physician's Request for Medical Service or Recommendation for Additional Conditions for Industrial Injury or Occupational Disease (C-9).

 

D.   BWC may approve and/or reimburse for psychiatric evaluations and/or treatment when an injured worker’s:

1.    Psychiatric condition is allowed in the claim;

2.    Psychiatric independent medical examination is scheduled by and for BWC purposes;

3.    Psychiatric condition is allowed in the claim and the injured worker or provider previously paid for  an examination performed to provide evidence to support the Motion (C-86);

4.    Evaluation and/or treatment is part of an approved vocational rehabilitation or catastrophic treatment plan;

5.    Evaluation is part of an authorized pre-admission evaluation for an approved chronic pain program;

6.    Evaluation and/or treatment is part of an authorized chronic pain program;

7.    Evaluation and/or treatment is part of an authorized detoxification or substance abuse program.

 

E.    Psychiatric conditions and compensation

1.    Specialties licensed to treat and who can certify periods of disability based on psychiatric allowance(s) include:

a.    Medical Doctors (M.D.), and

b.    Doctors of Osteopathic Medicine (D.O.), and

c.    Psychologists.

2.    Specialties licensed to treat without the supervision of a psychiatrist or psychologist (i.e., they may work independently to request treatment and provide medical/psychiatric services to an injured worker), but who cannot certify periods of disability or sign any forms used for compensation (e.g., MEDCO-14) include:

a.    Licensed Independent Social Workers (LISW); and

b.    Licensed Professional Clinical Counselors (LPCC).

 

F.    Psychiatric conditions and self-insured claims

1.    It is the policy of BWC not to schedule exams for psychiatric condition(s) requested in self-insured claims unless the Industrial Commission (IC) orders such an exam.

2.    If an exam is ordered, the self-insured employer is responsible for the cost of the psychiatric condition(s) independent medical examination scheduled at the request of the IC by BWC.

 


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