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OhioBWC - Basics: (Policy library) - File

Policy Name:

Miller Case Criteria

Policy #:

MP-13-01

Code/Rule Reference:

Ohio Administrative Code (OAC) 4123-6-16.2, and  4123-6-06.2; State, ex rel. Miller v. Indus. Comm., 71 Ohio St.3d 229 (1994)

Effective Date:

06/25/13

Approved:

Freddie Johnson, Chief of Medical Services (Signature on file)

Origin:

Medical Policy

Supersedes:

All policies and procedures, directives or memos regarding Miller case criteria that predate the effective date of this policy.

History:

New 08/31/12 Rev. 2/15/13; 6/25/13

Review date:

06/25/18

 

 

I. POLICY PURPOSE

 

The purpose of this policy is to ensure that the Bureau of Workers Compensation (BWC) complies with the criteria set forth in the case of State, ex rel. Miller v. Indus. Comm., hereafter Miller, and uses the criteria to evaluate and make determinations for authorization and reimbursement of medical services and supplies.

 

II. APPLICABILITY

 

This policy applies to staff of the BWC and Managed Care Organizations (MCOs) who approve purchases of medical services and supplies.  

 

III. DEFINITIONS

 

Miller criteria: mandatory evaluative three-prong test outlined by the Supreme Court of Ohio in the Miller case establishing that each prong must be met in order to allow reimbursement for any request for medical services/supplies. The three-part test was subsequently enacted as paragraphs (B)(1) through (B)(3) of 4123-6-16.2 of the Ohio Administrative Code. 

 

IV. POLICY

A.    It is the policy of BWC to authorize and reimburse for the service or supply that meets all three of the criteria outlined in Miller. The three criteria are:

1.    Are the medical services reasonably related to the industrial injury (allowed conditions)?

2.    Are the services reasonably necessary for the treatment of the industrial injury (allowed conditions)?

3.    Is the cost of these services medically reasonable?

B.    In determining whether the cost of services is medically reasonable under the third prong of the Miller criteria, BWC may consider whether a lesser cost service or supply meets the injured worker’s needs. In such instances, BWC may authorize reimbursement for the lesser cost service or supply. However, BWC may not interfere with an injured worker’s free choice of provider on the grounds that a different provider type or specialty could meet the injured worker’s needs at lesser cost.

C.   Miller clarifications/exceptions based on case law:

1.  Weight Loss Programs - BWC authorizes weight loss programs in claims in which obesity is not an allowed condition when it is documented that the weight loss will improve the allowed condition(s) in the claim.

a.  This improvement must be curative (therapeutic/healing, tending       to overcome disease and promote recovery); and

b.  Not merely palliative (pain relieving).

2.  Treatment directed specifically to a body part or specific condition of a body part - Treatment shall be considered only after the additional specific body part or specific condition of a body part has been allowed in the claim.

3.  Psychiatric treatment - Treatment shall only be approved when psychiatric conditions are allowed in the claim, unless otherwise permissible under BWC law or policy, as in catastrophic claims and as part of a vocational rehabilitation plan.

4.  Contributing Non-allowed Condition – Treatment that is independently required for the allowed condition(s) in the claim may be approved even though a contributing non-allowed condition exists and/or may also be addressed in the course of the treatment.

 

D.   For Non-allowed generalized conditions or diseases (e.g., obesity, diabetes, hypertension, etc.)

1.  Reimbursement may be considered for non-allowed generalized conditions or diseases when the Miller test is met, and one of the following is likely to occur:

a.  Treatment of the non-allowed generalized condition(s) has a positive impact on the treatment outcome of the allowed condition(s) in the claim; or

b.  The non-allowed generalized condition(s) becomes uncontrolled or temporarily exacerbated and the uncontrolled or temporarily exacerbated state is likely to delay, impede, or prevent treatment of the allowed condition(s) in the claim.

 In such instances, staff shall authorize medical services:

i.      Until the symptoms or condition returns to baseline; or

ii.     The temporary exacerbation has ended.

2.  If a pre-existing non-allowed generalized condition is not brought under control or never returns to baseline, consideration should be given to an additional allowance in the claim.

 

Below are case scenarios on how Miller case criteria should be applied to non-allowed generalized conditions.

 

A diabetic injured worker sustains a laceration to the hand. The claim is allowed for the hand laceration and appropriate medical treatment is provided for the allowed condition, but not the non-allowed generalized condition of diabetes. If, however, the hand becomes infected and the diabetes is out of control, it is reasonable under Miller to authorize payment for the treatment of the diabetes until it is stabilized. The rationale for this decision is that treatment of the diabetes may promote resolution of the infection in the hand laceration, thereby improving the allowed condition. Note that the diabetes is not an additional allowance in the claim and should only be treated until the non-allowed generalized condition is stabilized.

 

An injured worker with controlled high blood pressure is undergoing an outpatient surgical procedure for their allowed condition. In the recovery room the injured worker experiences a hypertensive emergency, is given an IV antihypertensive medication, and then admitted to the hospital for observation. Authorization for this IV medication, hospitalization and services until the high blood pressure is under control are reasonable. However, once the blood pressure is controlled and the patient is released from the hospital, treatment for the high blood pressure is the responsibility of the injured worker and is not reimbursable by BWC. The rationale for this decision is that it was the treatment of the allowed condition that temporarily exacerbated the pre-existing non-allowed generalized condition.

 

Below is a case scenario on how Miller case criteria should be applied to contributing non-allowed conditions.

 

An injured worker sustains an industrial injury to the left knee. Two conditions have been formally allowed in the IW’s claim: "contusion, left knee" and "internal derangement/tear medial meniscus left knee." The IW’s physician requests approval for arthroscopic knee surgery on the grounds that the allowed conditions require the arthroscopy, advising that while early arthritic changes appear to be present in the IW’s knee, the IW was having enough trouble from the allowed conditions to require the arthroscopic procedure.  The physician's preoperative and postoperative diagnoses include non-allowed "degenerative arthritis, left knee" as well as "contusion, left knee" and “internal derangement/tear medial meniscus, left knee". The arthroscopic knee surgery may be approved, even though the IW has a contributing non-allowed condition of “degenerative arthritis,” because the surgery was independently required for the allowed conditions.

 

Below is a case scenario on how medically reasonable cost should be considered in determining reimbursement for medical supplies and/or services.

 

It has been determined that an injured worker weighing 450 lbs. needs a bedside commode, and that the bedside commode is both reasonably related to and reasonably necessary for the treatment of the allowed conditions. In determining reimbursement for the bedside commode, two models are available, both of which would meet the IW’s needs and are comparable in all practical aspects (see comparison chart below).

BWC and the MCO may determine that the cost of the Brand A bedside commode is the medically reasonable choice as compared with the cost of Brand B. Padded seating, armrests, and backrest are not medically necessary to serve the IW’s needs, and by adding these amenities, it increases the cost by $278.77.

 

 

Brand

A

B

Weight capacity

1000 lbs

850 lbs

 

Construction

Heavy duty steel

Heavy duty steel

 

Arms

 

Drop arms

Drop arms

Seat width

 

23.5”

24”

Warranty

 

3 year warranty

Limited lifetime warranty

Height

Adjustable

Adjustable

 

Ameneties

None

Padded seat, arm rests and backrest

Price

$247.55

$526.32

 

 


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