New (non-established) or emerging treatments and services policy
Guidelines for providing new (non-established) or emerging treatments and services to workers
Background
WorkCover Queensland decisions regarding treatments and services are guided by the:
- Medical Services Advisory Committee (MSAC)
- Medicare Benefits Schedule (MBS)
- Prostheses List Advisory Committee (PLAC)
- Department of Health Prostheses List
- Pharmaceutical Benefits Advisory Committee (PBAC)
- Pharmaceutical Benefits Schedule (PBS)
- Australian Register of Therapeutic Goods (ARTG)
- evidence-based medicine (i.e. research papers, literature reviews, published guidelines and other valid external sources).
WorkCover defers to decisions made by these bodies where such decisions exist. Where such decisions do not exist, consideration will only be given to new (i.e. non-established) or emerging treatment and service requests, where the medical practitioner provides strong clinical evidence (National Health and Medical Research Council [NHMRC] Level 1 or 2) of the safety and efficacy of the treatment and/or service.
What WorkCover will pay for:
WorkCover will consider paying the reasonable costs of new (non-established) or emerging treatments and services (equipment, medications, prostheses, procedures, or surgeries) only in exceptional circumstances when required as a result of a work-related injury or illness. For a request to be considered by WorkCover, the requesting practitioner must provide strong clinical evidence of the safety and efficacy of the new (i.e. non-established) or emerging treatments and services.
New (non-established) or emerging treatments and services can be paid under the Workers’ Compensation and Rehabilitation Act 2003 (the legislation), when WorkCover considers:
- the treatment or service is reasonable and necessary to treat the accepted work-related injury, and
- the cost of the treatment or service is reasonable.
This policy should be read in conjunction with the following as relevant:
- NHMRC levels of evidence and grades for recommendations for developers of guidelines
- the relevant WorkCover Medical Table of Costs
- the relevant WorkCover surgical guidelines (e.g. Upper limb, Lower limb, Spinal, Pain interventions)
- other related WorkCover guides:
- Treatment and approvals
- Approved registered providers
- Mental Injury Treatment Guidelines.
NHMRC: Resources for guideline developers
NHMRC is currently working with an expert advisory committee to develop an online resource for guideline developers that will update NHMRC’s current Guide to the development, evaluation and implementation of clinical practice guidelines and accompanying handbooks.
Definitions
In this policy, new (non-established) or emerging treatments and services include (but are not limited to):
- Equipment and other interventions which are not regulated by the PBAC, MSAC or PLAC and are not the subject of a previous negative decision by the PBAC, MSAC or PLAC
- Medication not on the PBS and/or not registered with the ARTG and not the subject of a previous negative decision by the PBAC or the ARTG (this includes off-label prescribing, i.e. where the intended use differs from that in the product information in the form of dose, age indication or route)
- Prostheses not on the Prosthesis List and not the subject of a previous negative decision by the PLAC
- Procedures and operations not on the MBS and not the subject of a previous negative decision by the MSAC
- Other treatments (equipment, medications, prostheses, procedures, or surgeries) not covered by existing WorkCover policies.
Frequently asked questions (FAQs) in relation to new (non-established) or emerging treatments and services
WorkCover can pay the reasonable costs of these treatments and services that are:
- required as a result of a work-related injury or illness, and
- required following a reasonable trial of all available established treatments and services, and
- considered for an exceptional circumstance, and
- supported by strong clinical evidence (NHMRC Level 1 or 2), and
- the subject of a written request for prior approval from a medical practitioner, and
- in accordance with relevant WorkCover guidelines.
These can be performed or supplied by a qualified and registered:
- medical practitioner,
- dentist,
- optometrist,
- physiotherapist,
- psychologist,
- chiropractor,
- Chinese medical practitioner,
- occupational therapist,
- speech pathologist,
- counsellor or psychotherapist,
- rehabilitation counsellor or social worker,
- exercise physiologist,
- osteopath, or
- podiatrist.
For WorkCover to consider paying the reasonable costs of these treatments and services, a request must be made in writing to WorkCover and include the following information:
- diagnosis and relationship to the work-related injury or illness
- evidence (NHMRC Level 1 or 2) that the proposed treatment or service will be safe and effective. In exceptional circumstances, consideration may be given to a request for the new (i.e. non-established) or emerging treatment and service where evidence can be supplied that the proposed treatment is consistent with the Clinical Framework. Where multiple pieces of high-level evidence exist, all the evidence will be reviewed to determine if the treatment is in the worker’s best interests
- details of all previously trialled treatments and services for this diagnosis and their measurable outcomes
- if established treatments and services have not been trialled, reasons for going directly to a new (i.e. non-established) or emerging treatment and service must be given
- clinical indications for requested treatments or services
- description and expected costs of proposed treatment or service
- objective outcome measures to be used and timing of assessment
- expected outcomes from proposed treatment or service, including functional outcomes (such as return to work, increased independence in domestic duties, etc.) how and when effectiveness will be assessed
- future treatments and services planned if proposed treatment or service is successful or unsuccessful
- the urgency of the request
- the name and qualifications of the requesting provider
- the name, qualifications, skills, and experience of the provider(s) performing the treatment or service.
To assist WorkCover to determine a request for new (i.e. non-established) or emerging treatment and services, the request may be reviewed by an independent medical practitioner.
The independent medical practitioner may contact the requesting medical practitioner to seek further information and/or discuss the proposed treatment or service prior to making a recommendation to WorkCover regarding the request. WorkCover will respond to the request when they have received the independent medical practitioner’s recommendation.
Refer to the following resources:
- How to invoice WorkCover Queensland
- The current Medical and allied health services – Table of Costs, including who can provide services, the approved item numbers and the schedule maximum fees payable.
- WorkCover will assess the expected cost information provided by the requesting providers for reasonable cost on a case-by-case basis.
- WorkCover will communicate the reasonable cost to the requesting provider in writing in the treatment or service approval letter.
WorkCover will not pay for:
- off-label use of medication where there is insufficient evidence to support its use
- prostheses costs for surgically implanted prostheses except where prior approval has been obtained
- telephone calls and telephone consultations between providers and workers, and between other providers, including hospitals
- fees associated with cancellation or non-attendance, treatments, and services:
- which are part of any research project or experiment
- subcontracted to, or provided by, a provider who is not a registered and approved WorkCover Queensland provider
- provided by telephone (i.e., not face to face or video conferencing)
- provided more than once on the same day to the same worker
- for a person other than the worker
- for a condition that existed before the work-related injury or illness or that is not a result of the work-related injury or illness.