Rule 4123-6-34 | Payment for treatment of concussion injuries.
This rule governs the bureau's reimbursement for services in an allowed claim related to concussion. It is not meant to preclude, or substitute for, the health care provider's responsibility to exercise sound clinical judgment in light of current best medical practices when treating injured workers.
(A) As used in this rule, "concussion" means a type of traumatic brain injury induced by external force, which might include a bump or blow to the head, or a jolt or hit to the body, which causes the brain to bounce around or twist in the skull, causing chemical changes in the brain and sometimes stretching and damaging brain cells.
(1) Concussion is manifest by at least one of the following:
(a) Any alteration in mental state at the time of the accident (feeling dazed, disoriented, or confused);
(b) Any period of loss of consciousness;
(c) Any loss of memory for events immediately before or after the accident; or
(d) Focal neurological deficit that may or may not be transient, but where the severity of the injury does not exceed the following:
(i) A loss of consciousness for approximately thirty minutes or less;
(ii) After thirty minutes, an initial "Glasgow Coma Score" of 13-15; or
(iii) Post-traumatic amnesia not greater than twenty-four hours.
(2) A concussion may involve different symptoms, clinical profiles and subtypes, and different recovery trajectories, which may be influenced by a variety of risk factors. Kontos, Anthony P. and Michael W. Collins. Concussion: a clinical profile approach to assessment and treatment. Washington, DC: American psychological association (2018), p.5. Adapted with permission.
(3) In concussion, even though by definition brain injury has occurred, standard imaging studies such as CT scan and MRI will commonly be normal.
(B) As used in this rule, "clinical domains" related to concussion means the following group of signs or symptoms related to a specific body part or system:
(1) Anxiety and mood: including ruminating thoughts, difficulty concentrating, hypervigilance, or fastidiousness.
(2) Vestibular: including impaired balance and equilibrium, dizziness, nausea, or environmental sensitivity,
(3) Ocular: including impaired vision and visual tracking, impaired comprehension, trouble focusing, or distractibility.
(4) Sleep: including trouble falling asleep or sleeping more or less than usual.
(5) Cervical: including neck pain, stiffness, or reduced range of motion.
(6) Cognitive fatigue: including impaired thinking abilities, feeling slow or "one step behind", physical and mental fatigue, general headache, or sleep disturbance.
(7) Headache (migraine, cervicogenic, and tension headache): including variable and intermittent severe headache, nausea, photosensitivity, or vestibular migraine.
(8) Cognitive impairment: including impairment in attention, memory, executive function, language processing, or visual perception and processing.
(C) Notwithstanding any provision to the contrary in any other rule of the bureau, medical treatment reimbursement requests relating to the clinical domains set forth in paragraph (B) of this rule, submitted within six months from the date of injury, for treatment not to exceed six months from the date of injury, may be authorized in an allowed claim, without disclaimer, when:
(1) The documented mechanism of injury in the claim included a bump or blow to the head, or a jolt or hit to the body: and
(2) Signs or symptoms related to the clinical domains have manifested within six weeks of the date of injury; and
(3) The requested medical treatment is determined to be medically necessary and appropriate, and reasonably related to treatment of concussion, based on the medical evidence.
(D) When concussion or other conditions relating to the clinical domains set forth in paragraph (B) of this rule and treated pursuant to paragraph (C) of this rule are determined to require ongoing treatment beyond six months, the physician of record or treating provider may request these conditions be additionally allowed in the claim.