§1203.1. Definitions; medical treatment schedule; medical advisory council

A. For use in this Section, the following terms have the following meanings, unless clearly indicated otherwise by the context:

(1) "Assistant secretary" means an assistant secretary of the Louisiana Workforce Commission responsible for the functions of the office of workers' compensation administration.

(2) "Associate medical director" means a physician who is licensed to practice medicine in the state of Louisiana and has been chosen by the assistant secretary pursuant to R.S. 23:1203.1.1.

(3) "Council" means the medical advisory council appointed by the assistant secretary.

(4) "Medical director" means a physician who is licensed to practice medicine in the state of Louisiana and has been chosen by the assistant secretary pursuant to R.S. 23:1203.1.1.

(5) "Office" means the office of workers' compensation administration of the Louisiana Workforce Commission.

(6) "Schedule" means the medical treatment schedule to be developed by the council and promulgated by the office and the assistant secretary.

B. The assistant secretary shall, through the office of workers' compensation administration, promulgate rules in accordance with the Administrative Procedure Act, R.S. 49:950 et seq., to establish a medical treatment schedule.

(1) Such rules shall be promulgated no later than January 1, 2011.

(2) The medical treatment schedule shall meet the criteria established in this Section and shall be organized in an interdisciplinary manner by particular regions of the body and organ systems.

C. The schedule shall be developed by the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients, integrating clinical expertise, which is the proficiency and judgment that clinicians acquire through clinical experience and clinical practice, with the best available external clinical evidence from systematic research.

D. The medical treatment schedule shall be based on guidelines which shall meet all of the following criteria:

(1) Rely on specified, comprehensive, and ongoing systematic medical literature review.

(2) Contain published criteria for rating studies and for determining the overall strength of the medical evidence, including the size of the sample, whether the authors and researchers had any financial interest in the product or service being studied, the design of the study and identification of any bias, and the statistical significance of the study.

(3) Are current and the most recent version produced, which shall mean that documented evidence can be produced or verified that the guideline was developed, reviewed, or revised within the previous five years.

(4) Are interdisciplinary and address the frequency, duration, intensity, and appropriateness of treatment procedures and modalities for all disciplines commonly performing treatment of employment-related injuries and diseases.

(5) Are, by statute or rule, adopted by any other state regarding medical treatment for workers' compensation injuries, diseases, or conditions.

E. The medical advisory council shall develop guidelines in accordance with Subsections C and D of this Section and may amend the schedule in accordance with Subsection C and Paragraph (D)(2) of this Section before submission to the assistant secretary for initial and subsequent formal adoption and promulgation in accordance with the Administrative Procedure Act, R.S. 49:950 et seq.

F. The assistant secretary shall appoint a medical advisory council, which shall be selected in accordance with the following:

(1) The professional association in Louisiana that represents each discipline enumerated in this Subsection shall provide the assistant secretary the names of three nominees, from which at least one representative shall be chosen to represent his respective discipline on the council.

(2) The assistant secretary shall select at least one representative from each of the following disciplines or associations:

(a) Orthopedic surgeons.

(b) Neurosurgeons.

(c) Neurologists.

(d) Interventional pain management physicians.

(e) Family practice physicians.

(f) Physical and occupational therapists.

(g) Chiropractic Association of Louisiana.

(h) Psychologists and psychiatrists.

(3) The assistant secretary may consider and appoint additional representatives in order to fulfill his duties as defined in this Section.

(4) The initial members of the medical advisory council shall serve until August 14, 2011, and all subsequent members shall serve two-year terms beginning on August fifteenth of each odd-numbered year.

(5) The assistant secretary shall have the authority to contract with a medical director and with consultants to assist the assistant secretary and the medical advisory council in the establishment and promulgation of the schedule.

G. The medical advisory council shall:

(1) Review current guidelines and accepted medical treatments which meet the criteria set forth in Subsections C, D, and E of this Section.

(2) Provide recommendations to the assistant secretary for the designation of guidelines to be established and promulgated as the medical treatment schedule by the office.

(3) Provide any additional advice and counsel to the assistant secretary as may be reasonable and necessary, or as may be requested, relative to the effective and efficient delivery of quality medical services to injured workers.

H. The assistant secretary, with the assistance of the medical advisory council, is authorized to review and update the medical treatment schedule no less often than once every two years. Such updates shall be made by rules promulgated in accordance with the Administrative Procedure Act, R.S. 49:950 et seq. In no event shall the schedule contain multiple guidelines covering the same aspects of the same medical condition which are simultaneously in force.

I. After the promulgation of the medical treatment schedule, throughout this Chapter, and notwithstanding any provision of law to the contrary, medical care, services, and treatment due, pursuant to R.S. 23:1203 et seq., by the employer to the employee shall mean care, services, and treatment in accordance with the medical treatment schedule. Medical care, services, and treatment that varies from the promulgated medical treatment schedule shall also be due by the employer when it is demonstrated to the medical director of the office by a preponderance of the scientific medical evidence, that a variance from the medical treatment schedule is reasonably required to cure or relieve the injured worker from the effects of the injury or occupational disease given the circumstances.

J.(1) After a medical provider has submitted to the payor the request for authorization and the information required by the Louisiana Administrative Code, Title 40, Chapter 27, the payor shall notify the medical provider of their action on the request within five business days of receipt of the request. If any dispute arises after January 1, 2011, as to whether the recommended care, services, or treatment is in accordance with the medical treatment schedule, or whether a variance from the medical treatment schedule is reasonably required as contemplated in Subsection I of this Section, any aggrieved party shall file, within fifteen calendar days, an appeal with the office of workers' compensation administration medical director or associate medical director on a form promulgated by the assistant secretary. The medical director or associate medical director shall render a decision as soon as is practicable, but in no event, not more than thirty calendar days from the date of filing.

(2) If either party, the medical director, or associate medical director believes that a potential conflict of interest exists, he shall communicate in writing such information to the assistant secretary, who shall make a determination as to whether a conflict exists within two business days. The assistant secretary shall notify in writing the patient, the physician, and, if applicable, the attorney of his decision within two business days.

K. After the issuance of the decision by the medical director or associate medical director of the office, any party who disagrees with the decision, may then appeal by filing a "Disputed Claim for Compensation", which is LWC Form 1008. The decision may be overturned when it is shown, by clear and convincing evidence, the decision of the medical director or associate medical director was not in accordance with the provisions of this Section.

L. It is the intent of the legislature that, with the establishment and enforcement of the medical treatment schedule, medical and surgical treatment, hospital care, and other health care provider services shall be delivered in an efficient and timely manner to injured employees.

M.(1) With regard to all treatment not covered by the medical treatment schedule promulgated in accordance with this Section, all medical care, services, and treatment shall be in accordance with Subsection D of this Section.

(2) Notwithstanding any other provision of this Chapter, all treatment not specified in the medical treatment schedule and not found in Subsection D of this Section shall be due by the employer when it is demonstrated to the medical director, in accordance with the principles of Subsection C of this Section, that a preponderance of the scientific medical evidence supports approval of the treatment that is not covered.

N. The medical treatment schedule is not relevant nor shall it be considered as evidence of a medical provider's legal standard of professional care as contemplated by the Louisiana medical malpractice provisions, R.S. 40:1299.41 et seq.

O.(1) No member of the Medical Advisory Council acting within the scope of his official functions and duties shall be held individually liable for a policy recommendation or policy action by the council, unless damage or injury is caused by the member's willful or wanton misconduct.

(2) A person immune from liability under the provisions of Paragraph (1) of this Subsection shall not be subject to civil or administrative subpoena for his recommendations or exercise of judgment as a member of the council, including a subpoena seeking his oral or written testimony at trial, discovery, or other proceeding, and a subpoena duces tecum seeking documents, inspections, things or information in electronic or any other form.

Acts 2009, No. 254, §1; Acts 2010, No. 619, §1, eff. June 25, 2010; Acts 2012, No. 573, §1; Acts 2012, No. 811, §6, eff. July 1, 2012; Acts 2013, No. 317, §1; Acts 2014, No. 791, §9; Acts 2018, No. 380, §1, eff. June 30, 2018.