What WorkSafe will pay for

The WorkSafe Agent (the Agent) can pay the reasonable costs of clinically justified Implantable Pain Therapy when required as a result of a work-related injury or illness under Victorian workers compensation legislation.

WorkSafe adopts the Medicare Benefits Schedule (MBS) items, explanations, definitions, rules and conditions for surgical services provided by medical practitioners. This policy must be read in conjunction with the following:

  • Medical practitioner policy
  • Elective surgery policy
  • Private hospitals policy
  • Surgically implanted prostheses policy
  • Medicare Benefits Schedule (MBS)

Definitions

  • In this policy, Implantable Pain Therapy (IPT) is a procedure involving the use of an implantable prosthetic device to address persistent pain and may be considered when a range of alternatives for managing persistent pain have been fully explored. Many IPT procedures remain nonestablished or experimental.
  • There are three stages to IPT:
  • Stage 1: A trial of neurostimulation or a trial of intrathecal analgesia
  • Stage 2: Implantation of a permanent IPT device
  • Stage 3: IPT required for a technical purpose such as battery or device replacement
  • IPT incorporates:
  • intrathecal morphine infusion and other analgesic infusions (also known as intraspinal pumps)
  • neurostimulation/neuromodulation techniques such as:
  • spinal cord stimulation
  • subcutaneous electrical stimulation
  • peripheral nerve stimulation
  • deep brain stimulation
  • motor cortex stimulation
  • other implanted neurostimulation devices for pain.

Guidelines

What can the Agent pay for in relation to IPT?

The Agent can pay the reasonable costs of an IPT procedure where:

  • the persistent pain condition has resulted from a workrelated injury or illness
  • alternative options for managing persistent pain have been fully explored and have not been successful
  • it is safe, effective and clinically justified, based on the worker's physical, psychological and functional status
  • the procedure has an item number in the MBS
  • the anticipated implantable prosthesis is listed on and provided in accordance with the Surgically Implanted Prostheses Policy
  • it is required for a technical purpose, such as a battery/device replacement, reprogramming or a refill (where the initial IPT was paid for by the Agent).

The Agent can pay the reasonable costs of:

  • a trial of neurostimulation of a minimum of one week duration and a maximum of two week duration in an outpatient setting and approved by the WorkSafe or intrathecal analgesia trial approved by the WorkSafe
  • IPT approved by the WorkSafe following an approved, successful trial of neurostimulation or intrathecal analgesia
  • only one IPT for a worker unless a subsequent procedure is required for technical purposes and that procedure is approved by the WorkSafe
  • battery/device replacement approved by the WorkSafe following approved IPT
  • hospital services associated with IPT procedures
  • prostheses in accordance with the Surgically Implanted Prostheses Policy.

When replacement or modification of a prosthesis used for IPT is required, and the prosthesis is covered by a supplier/manufacturer warranty, it is the responsibility of the manufacturer to replace or modify the prosthesis or its components.

Who can provide IPT?

IPT is to be requested and performed by a registered medical practitioner with expertise in the area of IPT.

What information does the Agent require to consider paying for IPT?

To consider paying for IPT, the Agent requires information from the treating medical practitioner and information obtained by the Agent from other health providers.

Information required from the treating medical pracitioner

  • Prior approval is required in writing from the Agent prior to any IPT procedure.
  • The Agent requires a written request for IPT from the treating medical practitioner. IPT is to be requested and approved in stages and different information is required depending on the stage of treatment that is being requested.
  • The following sections outline in detail the information required from the treating medical practitioner to request IPT, depending on the stage of the treatment. The information required is necessary for the Agent to make an informed decision. Please note that if an IPT request does not include all the information required, the Agent will not review the request.

Stage 1: A trial of neurostimulation or a trial of intrathecal analgesia

The request for a trial of either neurostimulation or intrathecal analgesia should include an assessment and written clinical rationale from the treating medical practitioner, including:

  1. The condition(s) being treated.
  2. The relationship between the condition(s) being treated and the work-related injury or illness.
  3. A brief description of the IPT procedure with details of the prosthetic items to be used, in accordance with the Surgically Implanted Prostheses Policy
  4. The clinical indication for the IPT procedure, including reasons why more conservative treatments that the worker has tried for pain management have not been effective.
  5. A list of all current medications taken by the worker, including any medication dependency issues.
  6. Anticipated effects the IPT procedure will have on the worker's:
    • participation in activities of daily living and work
    • mobility
    • pain levels and mood
    • medication use (i.e. expected reductions).

7. Objective pre- and post-IPT outcome measures that will be used to measure the effectiveness of the procedure.

8. Anticipated treatment plan following IPT procedure, including:

  • the medications expected to be required
  • who will be responsible for the worker's short and long term care
  • who will be responsible for changing batteries, refills and reprogramming (where required)
  • other therapists to be involved to maximise functional gains following IPT, e.g. physiotherapist, occupational therapist, return to work specialist, etc.
  • other treatments being considered if the procedure is not successful.

Stage 2: Implantation of a permanent IPT device, following an approved trial

If the outcome of an approved trial of neurostimulation or intrathecal analgesia supports the implantation of a permanent IPT device, the Agent requires a request for a permanent IPT device from the requesting medical practitioner which includes: 1

  1. The objectively measured outcomes of the trial in order to assess a request for a permanent IPT.
  2. A brief description of the IPT procedure with details of the prosthetic items to be used, in accordance with the Surgically Implanted Prostheses Policy.

Stage 3: IPT required for a technical purpose such as battery or device replacement

The request from the requesting medical practitioner must include:

  1. Justification stating why the procedure or replacement is required.
  2. Evidence of the effectiveness of the IPT to date, including effect on the pain and function of the worker.
  3. A brief description of the IPT procedure with details of the prosthetic items to be used, in accordance with the Surgically Implanted Prostheses Policy.
  4. An indication of whether the replacement device parts are under warranty and if not, when the warranty on the parts expired. 5
  5. An indication of the urgency of the request.

Information the agent may obtain from other health providers

In addition to the information provided by the treating medical practitioner in the request for IPT, the Agent may arrange for the worker to be assessed by an independent medical examiner with expertise in IPT.

The Agent will also review information regarding a worker's psychological suitability to undergo IPT.

  • This information may be from:
  • an independent medical examination with a psychiatrist, arranged by the Agent; and/or
  • the worker's treating psychologist or treating psychiatrist, but only at the request of the Agent.

When will the Agent respond to a request?

  • To assist the Agent to make a decision regarding a request for IPT, an IPT request will be reviewed by a WorkSafe Medical Advisor. The Medical Advisor may contact the requesting medical practitioner to seek further information and/or discuss the proposed treatment prior to making a recommendation to the Agent regarding the request. The Agent will respond to the request when they have received the Medical Advisor's recommendation.
What are the WorkSafe's invoicing requirements?

Refer to the How to invoice WorkSafe guidelines.

What fees are payable for IPT?

The Agent can pay the reasonable costs of IPT in accordance with the:

  • Reimbursement Rates for Medical Services
  • Surgically Implanted Prostheses Policy
  • Private Hospitals Policy.
In relation to IPT, what will the Agent not pay for?

The Agent will not pay for:

  • treatment or services that are contra-indicated on physical, psychological or functional grounds
  • treatment or services that form part of a clinical trial
  • reports not requested by the Agent
  • services that are not in accordance with the MBS guidelines unless otherwise specified by the Agent
  • IPT where alternative options for managing persistent pain have not been fully explored
  • modification or replacement of an IPT device that is covered by supplier/manufacturer warranty
  • treatment or services for a person other than the worker
  • fees associated with cancellation or non attendance
  • provided outside Australia without prior written approval from WorkSafe
  • treatment or services provided by telephone or other non face to face mediums
  • the cost of telephone calls and telephone consultations between providers and clients, and between other providers, including hospitals.

Further information

Contact the referring Agent, email [email protected].