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Medical Services Review Board April 19, 2007 Minutes
Members present: Beth Baker, M.D. Barbara Baum, MS PT Michael Goertz, M.D. Rose Hatmaker Charles Hipp, M.D. Greg Hynan, D.C. Robert Meisterling, M.D. Jon Talsness, M.D. Members excused: Philip Bachman, M.D. Jeffrey Bonsell, D.C. Sharon Ellis, R.N. Elizabeth Mangold Robin Peterson, P.T. Andrew Schmidt, M.D. Elizabeth Shogren Members absent: Reed Pollack Andrea Trimble Hart Staff members present: Kate Berger Debbie Caswell William Lohman, M.D. Julie Marquardt Phil Moosbrugger Patricia Todd Visitors present: Dan Anderson; Purdue Marge Bigelow; MAPS Charles Cochrane Natalie Haefner; WCRA Mary Beth Johnson; Purdue Tom Mottaz; MTLA Harold Sadoff; MTLA, MSPHA David C. Wulff; MTLA

Chairperson Beth Baker called the meeting to order at 4:11 p.m. Robert Meisterling, M.D., was introduced as a new member of the Medical Services Review Board (MSRB) as a physician alternate. MSRB members, department staff members and the visitors introduced themselves. With no quorum present, the approval of the minutes, review of the comments received about the draft rules and voting on the department’s recommendations were tabled. The informational portions of the meeting were presented. Assistant commissioner’s announcements Patricia Todd said the Workers’ Compensation Advisory Council (WCAC) has a bill this session, but that discussions were ongoing and she was not sure whether it would pass. Todd noted the Department of Labor and Industry (DLI) had several meetings about its pay-for-performance initiative with the stakeholders in the workers’ compensation system. DLI will review the proposals that resulted from that input and will discuss it
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April 19, 2007

with relevant constituent groups. There was no timetable for the project. Todd will update the MSRB at a later meeting. Provider discipline report and managed care Julie Marquardt, medical policy specialist, reviewed the provider discipline report placed in members’ packets. Upon the receipt of a compliant, DLI will investigate and attempt to resolve it between the parties involved. If the parties cannot negotiate a settlement, an administrative law judge makes a recommendation to the MSRB for a decision. Marquardt noted DLI is proactive in resolving these complaints early, which is working. A visitor at the meeting suggested a pharmacist should serve on the MSRB. Lohman pointed out that the membership of the MSRB is set by statute. The board gets input from pharmacists when needed. Amendments to treatment parameters Lohman noted DLI was contacted by representatives from Medtronic who submitted materials recommending changes to the treatment parameters concerning spinal stimulators and morphine pumps. DLI is conducting an evaluation of the medical literature regarding these devices and hopes to present that review at the next meeting. Quorum At 4:32 p.m., a quorum was achieved. Charles Hipp made a motion to approve the minutes from the Nov. 9, 2006, meeting as presented. Barbara Baum seconded the motion. All voted in favor of the motion and it passed. Review of comments received about the draft rules Baum made a motion to have Lohman run this portion of the meeting. Hipp seconded the motion. All voted in favor of the motion and it passed. Lohman distributed copies of the comments DLI received about the five draft rules to the members. He also distributed tables for each rule that excerpted all of the comments received regarding that rule and arranged them with reference to rule provisions. The tables also contained a department recommendation in response to each comment. Lohman asked the MSRB to suspend the meeting rules of order and consider each of the recommendations as a motion made and seconded, ready for discussion and vote. In the case of a vote against a recommendation, members could propose an alternative or table the issue for further discussion at a later date.

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April 19, 2007

Baum made a motion to suspend the meeting rules of order and to adopt the method proposed by Lohman. Rose Hatmaker seconded the motion. All voted in favor of the motion and is passed. Lohman then proceeded to review the comments and the department’s recommendations. The actions taken by the MSRB on each comment are recorded in the tables attached to these minutes. All of the department’s recommendations were approved with the following exception. The board voted to table further discussion of the application of the rules regarding long-term use of opioid analgesics in cases where the treating health care provider has been prescribing opiates for more than three months but has not indicated an intention of prescribing them indefinitely (proposed MR 5221.6600 subpart 3 (2)). The board asked for further information and will take up this issue at its next meeting. The MSRB also directed the department to: change the word “physician” to “health care provider” wherever it appears in the rules regarding NSAIDs, muscle relaxers and narcotic analgesics; develop a definition of “medical contraindication” for review at the next MSRB meeting; and determine if the chiropractic practice of recommending OTC analgesics has any implications for these rules and report back to the board at its next meeting. Anyone interested in submitting additional comments was invited to e-mail them to Lohman at bill.lohman@state.mn.us. Lohman will forward any new comments, so members will have them before the next meeting. The meeting was adjourned at 6:28 p.m. Respectfully submitted,

Debbie Caswell Executive Secretary dc:s

MSRB meeting, April, 19, 2007 Comments received and actions taken RE: proposed rules for amendments to general parameters

01-18-07 draft

Comment Require prior notification for any diagnostics. Add rules for MRI scans of other body parts like the ones for low back pain Add medical imaging rules for lower extremity injuries Allow insurer to divert patients to lower cost providers of radiology services so long as they provide a comparable service. Allow the insurer to substitute a therapeutically equivalent implanted spinal cord stimulator. Is it possible to do a second FCE if the patient’s condition has deteriorated, changed after surgery, or the job duties change? Change title from RSD to CRPS Use the IASP definitions for CRPS Disagree with using injections, PT should be tried first

Actions taken No action; this would create an unnecessary burden No action at this time; MSRB will consider this issue in the future. No action at this time; MSRB will consider this issue in the future. No action at this time; MSRB will consider this issue in the future. No action at this time – DLI is currently doing a full scale review of spinal cord stimulators No action; departures are already available in the rules. This has not been an issue in regard to low back pain cases. Add CRPS to the title. Add the IASP definition as a third category in subpart 1A. No action; the rule does not prohibit the use of physical therapy as a first line of treatment.

p. 4, l. 45 & p. 6, l. 12 p. 8, l. 9 p. 8, l. 16 p. 8, l. 31

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MSRB meeting, April 19, 2007 Comments received and actions taken RE: proposed rules for nonsteroidal anti-inflammatories

12/7/06 draft

Comment Use of chemical names instead of trade names is confusing to everyone but a health care provider These rules eliminate any provider discretion and will cause providers to refuse wc patients Who decides what is the “lowest clinically effective dose” Add that preference should be given to etodolac, ibuprofen, nabumetone, and naproxen The duration of therapy and GI side-effects should preclude the listing of ketorolac Change “are another class” to “are a subclass” Change “but not to exceed” to “and not to exceed” The requirement to use generics makes no sense except to lower costs Delete generic diclofenac because of reports of increased cardiovascular toxicity One week trials are too short Who decides that the pain has been reduced by > 50% Who decides what is the shortest duration needed? The FDA maintains a warning against using COX-2 inhibitors in patients with aspirin allergy Add “non-acetylated salicylates” COX-2 inhibitors are very effective treatment; restricting their use in this way does not make sense

Actions taken No action; the chemical name is more inclusive No action; there is no evidence that other treatment parameters have had this effect Clarify that this decision is made by the treating physician No action; preference is being given to the least expensive medications; these are second line drugs No action; there is insufficient evidence to support this recommendation No action; the change has no effect on the substance of the rule No action; the change has no effect on the substance of the rule No action; generics are already required by other state laws Add a clarification – “unless there is a medical contraindication documented by the prescribing physician” No action; this was recommended by the MSRB Clarify that this decision is made by the treating physician Clarify that this decision is made by the treating physician Conform to FDA Moot if rules conform to FDA No action; the review of the evidence shows that they are no more effective than other NSAIDs

l. 3 l. 4 l. 6 l. 7 l. 12 l. 13

l. 14 l. 14 l. 19 l. 27-29 l. 27 l.31

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MSRB meeting, April 19, 2007 Comments received and actions taken RE: proposed rules for nonsteroidal anti-inflammatories l. 31 This item should note that if a patient is already taking aspirin then there is no advantage in using a COX-2 inhibitor Change to “documented history” Change “gastrointestinal disease” to “gastrointestinal bleed or peptic ulcer disease” Eliminate g.i. side-effects from non-selective NSAIDs as an indication for COX-2 inhibitors Would the gastroprotective agent be covered by WC Changes recommended by the department Frame the proposed rule as a subpart of a new treatment parameter with an introductory paragraph: “Subparts --- to --- of this rule do not require a physician to prescribe any class of drugs in the treatment of any patient, but apply only when the physician has elected to prescribe from one of the specified classes of drugs for the symptomatic relief of musculoskeletal pain.” Delete MR 5221.6200 subpart 10, 5221.6205 subpart 10, 5221.6210 subpart 10, 5221.6300 subpart 10: “Scheduled and nonscheduled medications” No action this is already part of the rule at l. 35-38

L.33 L. 33 l. 34 l. 37-38

No action; this is already required in the rule Change to “gastrointestinal bleed or gastrointestinal disease” No action; evidence shows that this is a legitimate indication for COX2 inhibitors No action; this is an issue that needs to be decided on a case-by-case basis Approved

Approved

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MSRB meeting, April 19, 2007 Comments received and actions taken RE: proposed rules for nonsteroidal anti-inflammatories l. 1 Add a definition: Approved

“Non-steroidal anti-inflammatory drugs are drugs with analgesic, antipyretic and anti-inflammatory effects. The term "non-steroidal" is used to distinguish these drugs from steroids. NSAIDs act as inhibitors of the enzyme cyclooxygenase. For the purposes of this rule NSAIDs includes arylalkanoic acids, 2-arylpropionic acids (profens), n-arylanthranilic acids (fenamic acids), pyrazolidine derivatives, oxicams, coxibs, sulphonanilides, and diflunisal but not other salicylates or acetaminophen.” l. 1 Change “relief” to “symptomatic relief” Approved Additional actions originating from member concerns expressed at the time of the meeting Physicians are not the only health care providers that can Change “physician” to “health care provider” prescribe medications l. 13 What constitutes a “medical contraindication” Develop a definition for consideration by the board Chiropractors may recommend OTC medications though The department is directed to investigate the issue and they cannot prescribe; what are the implications for this report back to the board. proposed rule?

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MSRB meeting, April 19, 2007 Comments received and actions taken RE: proposed rules for muscle relaxants

12/5/06 draft

Comment Use of chemical names instead of trade names is confusing to everyone but a health care provider These rules eliminate any provider discretion and will cause providers to refuse wc patients The exclusion of baclofen is short-sighted; it is very effective in patients with spinal cord trauma Who decides what is the “lowest clinically effective dose” Since a doctor can “defeat” the requirement for a generic by writing “Brand is Medically Necessary,” require the patient to pay the difference. The requirement to use generics makes no sense except to lower costs Eliminate carisoprodol because it is metabolized to meprobamate and is subject to abuse One week trials are too short Replace “pain” with “incidents of spasm” Who decides that the pain has been reduced by >50%? Require combinations when available Replace “indicated” to “authorized” Consider breaking down the use into acute and chronic indications Two week prescriptions are more expensive than one month prescriptions; allow one month prescriptions and

Actions taken No action; the chemical name is more inclusive No action; there is no evidence that other treatment parameters have had this effect Clarify that this rule only applies to the symptomatic relief of musculoskeletal pain Clarify that this decision is made by the treating physician No action; there is no authority to do this by rule

l. 3 l. 5 l. 8

l. 8 l. 9

l. 11 l. 13 l. 13 l. 14 l. 17, 27 & 29 l. 19 l. 22

No action; generics are already required by other state laws Add a clarification – “unless there is a medical contraindication documented by the prescribing physician” No action; this was recommended by the MSRB No action; this rule addresses the treatment of musculoskeletal pain Clarify that this decision is made by the treating physician No action; the treating physician should determine whether both drugs in a combination are needed No action; authorization is a payment concept; these rules address appropriate treatment No action; item B does differentiate by duration of condition No action; this is not medically appropriate

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MSRB meeting, April 19, 2007 Comments received and actions taken RE: proposed rules for muscle relaxants refills, and let the patient throw away what isn’t needed. Muscle relaxants should not be used for more than 4-6 weeks post injury One month’s worth of a muscle relaxant is inappropriate Muscle relaxants should only be used as needed in chronic conditions This contradicts the evidence that long-term muscle relaxant treatment is effective The exclusion of benzodiazepines is short-sighted; they are very effective in patients with spinal cord trauma The PDR says that benzodiazepines are effective muscle relaxants Changes recommended by the department Frame the proposed rule as a subpart of a new treatment parameter with an introductory paragraph: “Subparts --- to --- of this rule do not require a physician to prescribe any class of drugs in the treatment of any patient, but apply only when the physician has elected to prescribe from one of the specified classes of drugs for the symptomatic relief of musculoskeletal pain.” Delete MR 5221.6200 subpart 10, 5221.6205 subpart 10, 5221.6210 subpart 10, 5221.6300 subpart 10: “Scheduled and nonscheduled medications” Add a definition: “A muscle relaxant is a drug which decreases the tone of a muscle. For the purposes of this rule muscle relaxants include carisoprodol, chlorzoxazone, cyclobenzaprine,

l. 24 l. 25 l. 26 l. 26 l. 29 l. 29

No action; there is insufficient evidence to support this recommendation No action; there is insufficient evidence to support this recommendation No action; proposed rules would allow “as needed use” but would prohibit prolonged use (more than 3 months) No action; there is insufficient evidence to support this recommendation Clarify that this rule only applies to the symptomatic relief of musculoskeletal pain No action; evidence review shows that the benefits are outweighed by the side-effects Approved

Approved

l. 1

Approved

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MSRB meeting, April 19, 2007 Comments received and actions taken RE: proposed rules for muscle relaxants metaxalone, methocarbamol, orphenadrine, and tizanide but not other medications that may be used to treat spasticity.” l. 4 Change “treatment” to “symptomatic relief” Approved Additional actions originating from member concerns expressed at the time of the meeting Physicians are not the only health care providers that can Change “physician” to “health care provider” prescribe medications l. 9 What constitutes a “medical contraindication” Develop a definition for consideration by the board

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MSRB meeting, April 19, 2007 Comments received and actions taken RE: proposed rules for narcotic analgesics

12/5/06 draft

Comment Use of chemical names instead of trade names is confusing to everyone but a health care provider These rules eliminate any provider discretion and will cause providers to refuse wc patients Rules do not reflect current thinking about treatment of pain.

Actions taken No action; the chemical name is more inclusive

l. 2

l. (2) & 10 l. 4

l. 6 l. 8 l. 11

No action; there is no evidence that other treatment parameters have had this effect Clarify that these are rules for choice of narcotic whenever they are used and for prescribing for the acute use; add language to coordinate with rules for long-term use of opiates. Quantity limitations may lead to more frequent office visits No action; if so. those visits may be indicated for appropriate care Allow use of strong narcotic for severe pain No action; proposed rules do not prohibit use of strong narcotic for severe pain. Rules should take into account genetic characteristics of No action; proposed rules do not prohibit the treating the patient in regard to the conversion of codeine to physician from making these kinds of determinations. morphine or hydrocodone to hydromorphone Remove levorphanol: more potent than morphine with Add a clarification – “unless there is a medical longer half-life with euphoria as known side-effect contraindication documented by the prescribing physician” Add hydromorphone Accept; it was inadvertently left out of the list Break down into acute and chronic indications Clarify that these are rules for choice of narcotic whenever they are used and for prescribing for the acute use; add language to coordinate with rules for long-term use of opiates. Who decides what is the “lowest clinically effective dose” Clarify that this decision is made by the treating physician The requirement to use generics makes no sense except to No action; generics are already required by other state lower costs laws One week trials are too short No action; this was recommended by the MSRB

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MSRB meeting, April 19, 2007 Comments received and actions taken RE: proposed rules for narcotic analgesics l. 13 l. 11-13 l. 18 & 30 l. 24 Who decides that the pain has been reduced by >50%? Eliminate “one-week” and “in reducing the patient’s pain by at least 50%” Change “indicated” to “authorized” Two week prescriptions are more expensive than one month prescriptions; allow one month prescriptions and refills, and let the patient throw away what isn’t needed. Delete “worth” Limiting narcotics to 3 consecutive months seems to go against accepted medical practice The PDR says that meperidine is an effective analgesic. Delete item D; transcutaneous administration is very effective at minimizing side-effects and providing a stable blood level. The treating physician should be able to use patches if they are considered more effective. Add a new part addressing trans-mucosal drugs such as Actiq and Fentora: they have no indications in treating workers’ compensation patients Clarify that this decision is made by the treating physician No action; a 50% reduction is the consensus standard used in the medical literature to assess analgesic efficacy No action; authorization is a payment concept; these rules address appropriate treatment No action; this is not medically appropriate

l. 24 & 26 l. 27

l. 29 l. 32-33

l. 32-33

Accept No action; the rule does not limit narcotics to 3 consecutive months; it merely references another set of rules that deal with that situation. No action; evidence review shows that the benefits are outweighed by the side-effects No action; there is no evidence that these delivery systems are more effective or safer than oral dosing in patients with normal gastrointestinal absorption No action; there is no evidence that these delivery systems are more effective or safer than oral dosing in patients with normal gastrointestinal absorption Add a new item restricting the use of oral transmucosal or buccal preparations to the treatment of breakthrough pain in patients with a documented disorder that prevents the use swallowed medication.

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MSRB meeting, April 19, 2007 Comments received and actions taken RE: proposed rules for narcotic analgesics Changes recommended by the department Frame the proposed rule as a subpart of a new treatment parameter with an introductory paragraph:

Approved

l. 1

“Subparts --- to --- of this rule do not require a physician to prescribe any class of drugs in the treatment of any patient, but apply only when the physician has elected to prescribe from one of the specified classes of drugs for the symptomatic relief of musculoskeletal pain.” Delete MR 5221.6200 subpart 10, 5221.6205 subpart 10, Approved 5221.6210 subpart 10, 5221.6300 subpart 10: “Scheduled and nonscheduled medications” Add a definition: Approved

“An opioid is any agent that binds to opioid receptors. There are three broad classes of opioids: opium alkaloids, such as morphine and codeine; semi-synthetic opioids such as heroin and oxycodone; and fully synthetic opioids such as pethidine and methadone.” l. 4 Change “treatment” to “symptomatic relief” Approved Additional actions originating from member concerns expressed at the time of the meeting Physicians are not the only health care providers that can Change “physician” to “health care provider” prescribe medications What constitutes a “medical contraindication” Develop a definition for consideration by the board

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MSRB meeting, April 19, 2007 Comments received and actions taken RE: proposed rules for long-term use of opioids

12/7/06 draft

Comment These rules will cause providers to refuse wc patients These rules assume that most injured workers abuse narcotics and their doctors are co-conspirators. These rules cannot be handled by pharmacy adjudication software. Defining long-term use on the basis of the physician’s intention is vague; how is this identified? Defining long-term as more than 3 months seems too short a time to justify these draconian rules Requiring the patient to meet all of these criteria will allow the insurer to delay or deny treatment. Who decides this? Most injured workers are depressed; does this mean that everyone has to have a psychiatric evaluation? Who decides which specialist the patient sees? Require that the “physician specializing in chronic pain medicine” be Board-certified in pain management. Will the patient have to get testimonials from every physician they have ever seen to prove this? This would be a gross invasion of privacy. How is this determined? Delete; this is not a contraindication.

Actions taken No action; there is no evidence that other treatment parameters have had this effect No action; the rules do not make this assumption but rather reflect current medical standards for the use of long-term narcotics No action; these are not rules intended to be implemented through on-line adjudication of prescriptions. Clarify that this is documented by the treating physician in the medical record. Tabled for further discussion Clarify that this is determined by the treating physician and the decision documented in the medical record Clarify that this is determined by the treating physician and the decision documented in the medical record Clarify that this is determined by the treating physician and the decision documented in the medical record Clarify that this is determined by the treating physician and the decision documented in the medical record No action; this could unnecessarily restrict access. Clarify that this is determined by the treating physician and the decision documented in the medical record Clarify that this is determined by the treating physician and the decision documented in the medical record Clarify this by adding a definition of abuse.

p. 1, l. 5 p. 1, l. 8 p. 1, l. 21 p. 1, l. 23 p. 1, l. 25 p. 1, l. 26 p. 1, l. 27 p. 1, l. 29 p. 1, l. 31 p. 1, l. 31

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MSRB meeting, April 19, 2007 Comments received and actions taken RE: proposed rules for long-term use of opioids p.1, l. 37 - 45 p. 1, l. 39 p. 1, l. 46 p. 2, l. 1 p. 2, l. 13-45 p. 2, l. 20 p. 2, l. 22 p. 2, l. 27 p.2, l. 34 Delete; none of these are contraindications to treatment. No action – these are only POTENTIAL problems that should be considered by the treating physician prior to starting long-term opioid treatment No action recommended – this is only POTENTIAL problems that should be considered by the treating physician prior to starting long-term opioid treatment Clarify that this is determined by the treating physician and the decision documented in the medical record No action recommended; it is standard medical practice to solicit a consultant’s opinion regarding care in complicated cases. Tabled for further discussion No action; rules do not limit the prescriptions to 7 days but to multiples of 7 days. Clarify that this is not meant to restrict the patient’s access to other modalities of treatment that are otherwise allowed No action; the physician has complete discretion in developing a plan to handle these situations No action; the rule only requires that the physician documents that the discussion took place; this is similar to current procedures used in documenting consent to treatment. Clarify where the name of the proxy will be documented. Accept; some departure is needed to address unusual circumstances

This would eliminate all women between the ages of 1855. Does this require the treating physician to do lengthy evaluations and reports? This eliminates the treating physician’s discretion and places the decision in the hands of a consultant with less knowledge of the patient. This is an unreasonable burden. Limiting prescriptions to 7 days is more costly than 30 day prescriptions. This restricts the patient to a “Hobson’s” choice. This unnecessarily restricts the physician’s discretion and will lead to more ER visits This will require documentation and if it is missing the insurer will deny treatment

p.2, l. 39 p. 2, l 41-2

Require the proxy designation in writing Allow an alternative pharmacy in emergencies if approved by the treating physician or proxy

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MSRB meeting, April 19, 2007 Comments received and actions taken RE: proposed rules for long-term use of opioids p. 2, l. 44 This will require lengthy and burdensome documentation thus increasing costs. No action; the rule only requires that the physician documents that issue was considered; physicians treating workers’ compensation patients are already required to write work restrictions. No action; the treating physician and patient can enter into a new agreement if the condition changes. No action; this is not part of the current medical standards for the use of long-term narcotics No action; this would create an unnecessary burden on pharmacists No action; the rules do not make this assumption but rather reflect current medical standards for the use of long-term narcotics No action; the rules do not make this assumption but rather reflect current medical standards for the use of long-term narcotics Remove language that might be considered vague“actively monitor treatment” and “to be vigilant for signs of addiction” – these requirements are spelled out elsewhere No action; physicians already have obligations in this regard No action – This is a liability issue and outside of the authority of the TxParam. No action – This is a liability issue and outside of the authority of the TxParam.

p. 2, l. 47 p. 2, l. 47 P. 3, l.4 p. 3, l. 16 p. 3, l. 18 p. 3, l. 24-29

The written agreement must allow the physician to depart from the agreement whenever there are exigent circumstances Item D should include random drug testing. Require that the written agreement be given to the dispensing pharmacy. This is completely unreasonable and assumes that an injured worker is lying. This is completely unreasonable and assumes that an injured worker is lying. This suggests that the provider wouldn’t do this anyway and since it is vaguely written it will give the insurer reasons to deny treatment. Add “or distribution to others” What if the provider terminates treatment and the patient goes and gets narcotics from someone else, does the insurer have to pay? What if the provider terminates treatment and the patient has become dependent on the narcotics and medicallymonitored withdrawal is necessary, does the insurer have to pay?

p. 3, l. 26 p. 3, l. 27-29 p. 3, l. 27-29

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MSRB meeting, April 19, 2007 Comments received and actions taken RE: proposed rules for long-term use of opioids p. 3, l. 32 p. 3, l. 37 p. 4, l. 7 Item E should include a requirement to report suspected diversion to the appropriate state agency. Make follow-up monthly during the first year and no less than quarterly thereafter. Change to “Board-Certified Pain Medicine Specialist” Add a new section specifying what happens to a provider who violates these rules Specify what an insurer can do if the rules are not followed Add a section that forbids the use of trans-mucosal drugs Changes recommended by the department Change “oral narcotic medications and to transdermal narcotic” to “oral., oral transmucosal, buccal and transcutaneous narcotic medications” Add language clarifying that the choice of narcotic medication used is governed by the rules on narcotic analgesics Change “at any time” to “if” Add language to allow a new agreement, superseding any previous agreement, whenever it is deemed medically necessary by the treating provider. No action; a provider’s obligations in this circumstance are governed by the licensing boards. No action; this would create an unnecessary burden No action; this could unnecessarily restrict access. No action; rules already exist for provider discipline. No action; the insurer has the same options as they do for any other dispute about treatment No action; defer this to the rules regarding choice of opiate medications. Approved

p. 1, l. 16 p. 1, l. 18 p. 3, l. 28 p. 3

Approved

Approved Approved

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