Claims Adjudication Tune-Up (CAT-U)
March 2025 Edition
Welcome to Self-Insurance’s (SI) Claims Adjudication Tune-Up (CAT-U) newsletter. This is where the Washington State Department of Labor & Industries (L&I) shares best practices and information, as well as highlight opportunities for improvement. The focus of this edition of CAT-U is Treatment of Unrelated Conditions.
Legal Corner
Washington Administrative Code (WAC) Review: WAC 296-20-055 “Limitation of treatment and temporary treatment of unrelated conditions when retarding recovery.”
…When an unrelated condition is being treated concurrently with the industrial
condition, the attending doctor must notify the department or self-insurer immediately
and submit the following:
(1) Diagnosis and/or nature of unrelated condition.
(2) Treatment being rendered.
(3) The effect, if any, on industrial condition.
Temporary treatment of an unrelated condition may be allowed, upon prior approval
by the department or self-insurer, provided these conditions directly retard recovery
of the accepted condition.
…, reports must be submitted monthly outlining the effect of treatment on both the
unrelated and the accepted industrial conditions.
Take away: When an unrelated condition is delaying recovery of the accepted condition(s), temporary treatment can be covered with prior approval of the insurer. The “Treatment Decision” template must be used, and should indicate that treatment is authorized on a temporary basis with an explanation.
Some examples could include:
- Smoking cessation (see coverage decisions “Tobacco Cessation Treatment for
Surgical Care”)
- Obesity treatment (see Claim Adjudication Guidelines “Obesity Treatment Programs”)
- Blood Sugar management for diabetics (See A1c recommendation under the "Lumbar Spine Surgery Guidelines”)
- Unrelated mental health conditions
Washington Administrative Code (WAC) Review: WAC 296-20-03013 “Will the department or self-insurer pay for a denied outpatient drug in special circumstances?”
Some of the drugs that are routinely denied may be covered in special circumstances.
Requests for coverage under special circumstances require authorization prior to
treatment. Examples of drugs that may be covered in special circumstances include:
• Drugs and medications to treat unrelated conditions when retarding recovery;
• Special treatments for unique catastrophic injuries.
The department may require written documentation to support the request.
Take away: The coverage of drugs for outpatient treatment of unrelated conditions may be allowed depending on the condition being treated. Drugs for treatment of obesity are not covered, but smoking cessation drugs like Wellbutrin may be coverable. Careful attention must be paid to the proposed treatment plan, the department’s drug policies, rules and guidelines before authorizing drug coverage for treatment of unrelated conditions.
News You Can Use
Case Law / Significant decision – In re John Galen, BIIA Dec., 03 18491 (2004)
Summary: Mr. Galen sustained an industrial injury to his neck and low back on May 20, 1999. Sometime in the fall of 2001, his physician recommended a full cervical fusion, but declined to perform the surgery until Mr. Galen, a smoker since 1971, abstained from smoking for a specific period of time. Mr. Galen wanted to stop smoking and tried a number of modalities to do that, but was unsuccessful. For this reason, the department suspended benefits.
He appealed, and the board found that his behavior was not considered non-cooperation.
The board reversed the department’s decision, citing Mr. Galen’s willingness to have the surgery and that he was taking steps to quit. His lack of success did not amount to noncooperation.
Claim impact: Suspension of benefits for non-cooperation requires behavior that obstructs or delays the administration of a claim. The behavior must be deliberate and calculated to obstruct. Behavior that is not designed or intended to obstruct or delay is not non-cooperation. A worker who is not meeting the goal(s) of temporary treatment for an unrelated condition is not necessarily non-cooperative. Rather than suspending benefits, other avenues of claims management may need to be explored.
Trainer’s Trivia
What was the first anti-smoking medication and when was it approved for use in the U.S.?
Answer to February 2025 Trivia: Per the Centers for Disease Control (CDC), 805,000 heart attacks occur in the US every year.
More reading/resources:
WAC 296-14-410 - Reduction, suspension, or denial of compensation as a result of noncooperation.
Medical Aid Rules – Payment Policies Chapter 21: Obesity Treatment.
Self-Insurance Claim Adjudication Guidelines, Medical Treatment Chapter sections:
“Temporary Treatment of Conditions Delaying Recovery”
“Obesity Treatment Programs”
“Tobacco Cessation”
Oien v. Department of Labor & Industries (1994): Addresses whether time-loss benefits are payable when the unrelated condition is the only cause of disability.
For more information, email: SITrainerQuestions@Lni.wa.gov
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