Non-established, new or emerging treatments and services policy

What WorkSafe will pay for

The WorkSafe Agent (the agent) can consider paying the reasonable costs of non-established, new 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 the agent, the requesting practitioner must provide strong clinical evidence of the safety and efficacy of the non-established, new or emerging treatments and services. 

Non-established, new or emerging treatments and services can be paid under Victorian workers compensation legislation (the legislation). 

Background

WorkSafe decisions regarding treatments and services are guided by the Medical Services Advisory Committee (MSAC), the Medicare Benefits Schedule (MBS), the Prostheses List Advisory Committee (PLAC), the Department of Health and Ageing Prostheses List, Pharmaceutical Benefit Advisory Committee (PBAC), the Pharmaceutical Benefits Schedule (PBS), the Australian Register of Therapeutic Goods (ARTG), and evidence-based medicine. 

WorkSafe defers to decisions made by these bodies where such decisions exist. Where such decisions do not exist, consideration will only be given to non-established, new or emerging treatments and services requests, where the medical practitioner provides strong clinical evidence (National Health * Medical Research Council [NHMRC] Level 1 or 2) of the safety and efficacy of the treatment and/or service.

This policy should be read in conjunction with the following as relevant:

• NHMRC levels of evidence and grades for recommendations for developers of guidelines
• Medical practitioner services policy
• Elective surgery services policy
• Pharmacy policy
• other related WorkSafe policies.

Definitions

In this policy, non-established, new 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 vitamins, minerals, and 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 WorkSafe policies.

Guidelines

What can the agent pay for in relation to non established, new or emerging treatments and services?

The agent can pay the reasonable costs of non-established, new or emerging treatments and services that are:

• required as a result of a work-related injury or illness
• required following a reasonable trial of all available established treatments and services
• considered for an exceptional circumstance
• supported by strong clinical evidence (NHMRC Level 1 or 2)
• the subject of a written request for prior approval from a medical practitioner
• in accordance with relevant WorkSafe guidelines

Who can provide non-established, new or emerging treatments and services?

Non-established, new or emerging treatments and services can be performed or supplied by:

• a qualified and registered medical practitioner, dentist, optometrist, physiotherapist, chiropractor, osteopath or podiatrist, or
• a provider approved by WorkSafe to provide that service

What information does the agent require to consider paying for non-established, new or emerging treatments and services?

For the agent to consider paying the reasonable costs of non-established, new or emerging treatments and services, a request must be made in writing to the agent 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 a non-established, new or emerging treatment or 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 client's best interests
• details of all previously trialed treatments and services for this diagnosis and their measurable outcomes
• if established treatments and services have not been trialed, reasons for going directly to a non-established, new or emerging treatment or 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

A request for non-established, new or emerging treatments and services will not be considered without the above information.

When will the agent respond to a request?

To assist the agent to make a decision regarding a request for non-established, new or emerging treatments and services, the request will be reviewed by a WorkSafe Medical Advisor or Clinical Panel member. The Medical Advisor or Clinical Panel member may contact the requesting medical practitioner to seek further information and/or discuss the proposed treatment or service 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 or Clinical Panel member's recommendation.

What are WorkSafe's invoicing requirements?

Refer to the:

What fees are payable for non-established, new or emerging treatments and services?

• WorkSafe will assess the expected cost information provided by the requesting providers for reasonable cost on a case by case basis.
• WorkSafe will communicate the reasonable cost to the requesting provider in writing in the treatment or service approval letter.

In relation to non-established, new or merging treatments and services, what won't the agent pay for?

The agent 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
• vitamins or minerals or any therapeutic good that has been listed, as opposed to registered, on the ARTG except for those described in Pharmacy Policy
• lokomat Body Weight Supported Treadmill Training (BWSTT) therapy (see the Evidence Review)
• 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 WorkSafe provider
  • provided by telephone or other non face to face medium
  • 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

Further information

Contact the referring agent or email [email protected].