24.29.1645    EXPEDITED CASE REVIEW FOR PRESCRIPTION MEDICATIONS BY DLI MEDICAL DIRECTOR

(1) Expedited case review is available only when insurer declines to authorize further dispensing of an already prescribed medication and halting the supply of that medication appears likely to result in a medical emergency. 

(2) A medical emergency occurs when all three of the following circumstances are present:

(a) the medical condition has a sudden onset;

(b) the medical condition manifests itself by acute symptoms of sufficient severity, including severe pain; and

(c) in the absence of immediate medical attention, the medical condition could reasonably be expected to result in:

(i) placing the injured worker's health or bodily functions in serious jeopardy; or

(ii) a serious dysfunction of any body organ or part of the injured worker.

(3) An expedited case review may be requested concurrently with a demand for mediation on the dispute concerning the medication.

(4) An expedited case review may only be requested within 14 days of the insurer's denial of, or refusal to authorize further dispensing of an already prescribed medication.

(5) A request for an expedited case review must be supported by such written information as the treating physician considers pertinent to the treating physician's opinion that a medical emergency is likely to occur as a result of the denial of the medication.

(6) The expedited medical review will be conducted within three business days of receipt by the department of a written request for an expedited medical review. The findings of the expedited medical review must be in writing and be based on the information provided by the treating physician, along with the reasoning given by the insurer or its agent for the denial.

(7) The findings of the medical director regarding whether or not a medical emergency is likely to occur as the result of not providing the further dispensing of medication as prescribed by the treating physician may be offered in evidence in mediation or the Workers' Compensation Court.

(8) If the findings of the medical director are that no medical emergency is likely to occur as a result of the insurer's denial, then the medical director shall further consider the matter of the denial under the independent medical review procedures provided for by ARM 24.29.1641.

 

History: 39-71-203, 39-71-704, MCA; IMP, 39-71-704, MCA; NEW, 2018 MAR p. 2531, Eff. 1/1/19.