Information required for proactive allowance

For BWC to consider a proactive allowance request, please forward the following medical data to the assigned managed care organization (MCO). The MCO will submit the following information to BWC:

• Supporting medical documentation, including clinical examination and diagnostic test findings;
• Current treatment plan;
• International Classification of Diseases (ICD-9) code for requested diagnosis (include specific diagnosis description, i.e., 722.10 Lumbar HNP, L4-L5, and identify if it is a primary ICD-9;
• ICD-9 location (right, left or bilateral) when applicable;
• ICD-9 site (digits, teeth or body part) when applicable;
• A causality statement indicating how the injury resulted (i.e., is the diagnosis causally related to the industrial accident?).

BWC will consider the physician’s recommendation of an additional
condition(s) when the Physician's Request for Medical Service or Recommendation for Additional Conditions for Industrial Injury or Occupational Disease (C-9) and/or medical evidence is dated within one year from the date of injury and the evidence clearly supports the condition. You must clearly define the medical documentation, mechanism of injury and time sequence, and support the additional allowance recommendation.

BWC will not consider proactively allowing psychiatric or chronic conditions that may be the result of natural deterioration or degenerative processes. These include conditions such as, arthritis; spinal stenosis; spondylolisthesis; degenerative disc disease, or aggravation of a pre-existing condition or disease; or less specific diagnosis of disorders such as myalgias, arthalgias or reflex sympathetic dystrophy.