(1) The department adopts the utilization and treatment guidelines provided by this rule to set forth the level and type of care for primary and secondary medical services. As provided by 39-71-704, MCA, there is a rebuttable presumption that the Montana Guidelines establish compensable medical treatment for primary and secondary medical services for the injured worker. The applicable utilization and treatment guidelines are available electronically at the web site: http://www.mtguidelines.com; or a printed copy may be obtained for the cost of reproduction from the Employment Relations Division, Department of Labor and Industry, P.O. Box 8011, Helena, MT 59601-8011. The Montana Guidelines incorporated by reference apply as follows:
(a) for medical services provided on or after July 1, 2023: "Montana Utilization and Treatment Guidelines, 8th edition, 2023"; and
(b) all prior Utilization and Treatment Guidelines starting July 1, 2011, are available on the department's website or by contacting the department to request a copy.
(2) The Montana Guidelines consist of the following ten chapters and General Guideline Principles which are included at the beginning of each chapter:
(a) Low Back Pain;
(b) Shoulder Injury;
(c) Thoracic Outlet Syndrome;
(d) Lower Extremity;
(e) Chronic Pain Disorder;
(f) Cervical Spine Injury;
(g) Complex Regional Pain Syndrome;
(h) Mild Traumatic Brain Injury;
(i) Moderate/Severe Traumatic Brain Injury; and
(j) Cumulative Trauma Conditions.
(3) The utilization and treatment guidelines adopted in (1) are to be read in conjunction with the Centers for Disease Control publications:
(a) "CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016"; and
(b) 2018 edition of "Implementing the CDC Guideline for Prescribing Opioids for Chronic Pain."
(4) When providing treatment for primary and secondary medical services to an injured worker, all health care providers shall use the Montana Guidelines adopted by reference in (1).
(a) In cases where treatment(s) or procedure(s) are recommended by the Montana Guidelines, and treatment is provided in accordance with the guidelines, prior authorization is unnecessary unless the Montana Guidelines specify otherwise.
(b) The department recognizes that medical treatment may include deviations from the Montana Guidelines as individual cases dictate. The provider or interested party shall follow the procedure for prior authorization under ARM 24.29.1621 for cases in which treatments or procedures are requested that are:
(i) not specifically addressed or recommended by the Montana Guidelines for a body part that is covered by a guideline;
(ii) after maximum medical improvement; or
(iii) beyond the duration and frequency limits set out in the guidelines.
(c) An insurer is not responsible or liable for treatment(s) or procedure(s) as set out in (3)(b) unless:
(i) prior authorization is obtained from the insurer pursuant to 39-71-704, MCA, and in accordance with ARM 24.29.1621; or
(ii) the treatment(s) or procedure(s) were provided in a medical emergency.
(d) For those body parts not included in one of the guideline chapters, providers must apply and follow the general guideline principles that are found at the beginning of each chapter, and an insurer is liable for reasonable medical treatment.
(5) All insurers shall routinely and regularly review claims to ensure that care is consistent with the Montana Guidelines adopted by reference in (1) and (7).
(6) The provisions of this rule apply to medical services provided on or after July 1, 2011.
(7) Effective April 1, 2019, the formulary adopted in ARM 24.29.1616 is considered to be a part of the Montana Guidelines.