Fibromyalgia

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Fibromyalgia is a complex pain disorder that raises many questions for providers, particularly as to whether this condition is related to the industrial insurance system. The purpose of this bulletin is to answer a few of those questions:

Is fibromyalgia accepted as an industrial injury or occupational disease?

If a provider asserts a worker's fibromyalgia is related to the industrial injury or occupational exposure, what type of documentation should be submitted to support this contention?

Will the department or self-insurer pay for short-term treatment of fibromyalgia?

Is fibromyalgia accepted as an industrial injury or occupational disease?

The Office of the Medical Director at the Department of Labor & Industries, in collaboration with the Washington State Medical Association's Industrial Insurance Guideline Subcommittee, studied fibromyalgia and the medical literature that addresses the causes of fibromyalgia. After careful consideration, it was determined that there is not sufficient medical data at this time to establish a causal relationship between an industrial injury or occupational exposure and the subsequent development of fibromyalgia.

Based on this lack of scientific evidence the department does not generally recognize fibromyalgia as an industrial injury, an occupational disease, or an aggravation to a pre-existing condition.

The worker's health care provider may submit additional information, as described below, that the provider believes rebuts, or challenges, this general policy for an individual worker.

If a provider asserts a workers fibromyalgia is related to the industrial injury or occupational exposure, what type of documentation should be submitted to support this contention?

A provider who feels that a worker's fibromyalgia is causally related to an industrial injury or occupational disease is encouraged to submit additional information to support that diagnosis. The kinds of information useful in this regard include:

1. Case-specific information linking the injury to the occurrence of fibromyalgia.

Case-specific information might include, but is not limited to:

Evidence of a temporal relationship to the worker's industrial injury or occupational exposure (e.g. the injury precedes all symptoms of fibromyalgia or symptoms of potentially crossover disorders such as chronic fatigue syndrome),

Documentation that the worker's diagnosis of fibromyalgia meets the American College of Rheumatology's 1990 Criteria for the Classification of Fibromyalgia,

A biological and clinically justifiable rationale for the relationship between the industrial injury and the occurrence of fibromyalgia. The biological rationale should include a discussion based on accepted principles of biological sciences (anatomy, physiology, biochemistry, etc.) as to how the industrial injury caused the condition.

2. Scientific studies that address the relationship between individual injuries and the occurrence of fibromyalgia.

The provider is encouraged to submit published scientific studies supporting the contention of causality. In 1996, and again in 1997 and 1998, the department reviewed the existing scientific literature on this subject and found insufficient medical data to establish a causal relationship between a traumatic injury or occupational exposure and the development of fibromyalgia. Therefore, it is particularly important that the provider point out any new studies or new analyses of old studies that he or she feels supports a different conclusion regarding causality.

Effective January 1, 1999, State Fund claim managers will automatically request this information from the attending physician whenever fibromyalgia is contended on a claim Information submitted by the provider to support the causal relationship will be reviewed by department medical staff before a claim adjudication decision is made.

Will the department or self-insurer pay for short-term treatment of fibromyalgia?

Temporary treatment as an aid to recovery

In general, fibromyalgia is not an accepted condition and treatment is not allowed. However, if fibromyalgia is directly retarding recovery of the accepted industrial injury or occupational disease, the department or self- insurer may authorize temporary treatment per WAC 296-20-055. Temporary treatment can be authorized when all of the following conditions are met:

The accepted industrial injury is not stable,

Fibromyalgia is directly retarding recovery of the accepted industrial injury or occupational disease, and

The required documentation is submitted (see authorization and documentation requirements below).

Treatment as an aid to recovery will be authorized for no longer than 90 calendar days. If the worker has reached maximum recovery from the accepted industrial injury or occupational disease prior to the 90-day period, the fibromyalgia treatment will be terminated at that time.

What are the authorization requirements?

The provider must obtain prior authorization to treat fibromyalgia as an aid to recovery. The department or self-insurer will not pay for treatment for fibromyalgia as an unrelated condition unless specifically authorized.

To request prior authorization, the provider must submit the following in writing to the department or self-insurer:

Adequate documentation that the worker's diagnosis of fibromyalgia meets the American College of Rheumatology's (ACR) 1990 Criteria for the Classification of Fibromyalgia

An explanation of how fibromyalgia, as an unrelated condition, is affecting the accepted industrial condition, and

A treatment plan.

Note: The State Fund's Provider Toll Free staff will not be able to authorize these services.

What type of treatment may be allowed for the temporary treatment of fibromyalgia?

The department or self-insured employer is most likely to approve treatment plans that include conservative, non-invasive treatment that the scientific literature has shown to be effective in the short term. Such treatment includes, but may not be limited to:

Physical therapy,

Low dose tricyclic anti-depressants,

Muscle relaxants on a time-limited basis, or

Spinal manipulations.

The department or self-insured employer will not approve invasive therapies or treatments whose effectiveness has not been documented for even the short-term. The following types of treatment will not be approved for the treatment of fibromyalgia:

Trigger point injections,

Methotrexate,

Opioids, or

NSAIDs.

Note: Fibromyalgia may coexist with other conditions for which such therapies may be indicated.

What are the documentation requirements?

When treating an unrelated condition, the attending physician must submit a report every 30 days outlining the effect of the treatment on both the unrelated and the accepted industrial conditions.

Because fibromyalgia does not have a unique diagnosis code, we ask that providers use ICD.9 code 729.1 (myalgia) on bills submitted for treatment of fibromyalgia.

Temporary treatment of unrelated conditions when retarding recovery WAC 296-20-055

The American College of Rheumatology's 1990 Criteria for the Classification of Fibromyalgia[*]

For classification purposes, patients will be said to have fibromyalgia if both criteria are satisfied. Widespread pain must have been present for at least 3 months. The presence of a second clinical disorder does not exclude the diagnosis of fibromyalgia.

1. History of widespread pain

Pain is considered widespread when all of the following are present: pain in the left side of the body, pain in the right side of the body, pain above the waist, and pain below the waist. In addition, axial skeletal pain (cervical spine or anterior chest or thoracic spine or low back) must be present. In this definition, shoulder and buttock pain is considered as pain for each involved side. "Low back" pain is considered lower segment pain.

2. Pain, on digital palpation, must be present in at least 11 of the following 18 tender point sites:

Occiput - bilateral, at the suboccipital muscle insertions

Low cervical - bilateral, at the anterior aspects of the intertransverse spaces at C5-C7

Trapezius - bilateral, at the midpoint of them upper border

Supraspinatus - bilateral, at origins, above the scapula spine near the medial border

Second rib - bilateral, at the second costochondral junctions, just lateral to the junctions on upper surfaces

Lateral epicondyle - bilateral, 2 cm distal to the epicondyles

Gluteal - bilateral, in upper outer quadrants of buttocks in anterior fold of muscle

Greater trochanter - bilateral, posterior to the trochanteric prominence

Knee - bilateral, at the medial fat pad proximal to the joint line

Digital palpation should be performed with an approximate force of 4 kg. For a tender point to be considered "positive" the subject must state that the palpation was painful. 'Tender" is not to be considered "painful."

[*]Frederick Wolfe, et.al., The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia, Report of the Multicenter Criteria Committee, Arthritis and Rheumatism, Vol. 33, No. 2 (February 1990).

Correspondence:

Department of Labor and Industries Health Service Analysis P.O. Box 44322 Olympia, Washington 98504 USA

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