2019 EXPEDITED RULES FOR TREATMENT OF POST-TRAUMATIC STRESS DISORDER (PTSD)

Pursuant to Minn. Stat. § 176.83, subd. 5(b)(8), the Commissioner of the department of Labor and Industry established criteria for the treatment of PTSD through an expedited rulemaking process. The standards and procedures have been established for the treatment of employees with a compensable mental impairment of PTSD as defined by statute. The rules governing treatment for PTSD are now effective. The rules and their applicability have been summarized below.

Applicability and Effective Date

Unless otherwise specified, the treatment parameters are deemed effective as of May 4, 2020. They will apply to all treatment provided for PTSD after the effective date, regardless of date of injury.

For patients receiving treatment for PTSD before May 4, 2020, the payer must send the provider, patient, and patient’s attorney of record (if any) written notice of the PTSD treatment rules at least 90 days before denying payment based on failure to comply with the rules.

Diagnosis, Initial Evaluation, and Treatment Plan

1. Diagnosis

The diagnosis of PTSD must be made by a licensed psychiatrist or psychologist. The diagnosis must also meet the criteria for a diagnosis of PTSD as provided in the most recently published edition of the Diagnostic and Statistical Manual of Mental Disorders by the American Psychiatry Association (DSM-V).

2. Initial Evaluation

Once a diagnosis of PTSD is confirmed, a mental health care provider as defined in Minn. R. 5221.6700 subp. 2(A)(5) must complete an initial evaluation using a tool validated in peer review scientific literature for the assessment of PTSD symptoms and functional status. The provider must be one who has experience treating patients with PTSD and whose practice primarily involves mental health treatment. When available, assessment tools must be based on the most recently published edition of the DSM.

Pursuant to Minn. R. 5221.6700, Subp. 3(B)(1-7), the initial evaluation shall include the following summarized determinations:

1. The employee’s functional status;

2. Family history;

3. Any prior mental health conditions or treatment;

4. Any risk of self-harm or harm to others;

5. Whether the employee has comorbid physical or psychiatric disorders;

6. Whether psychotherapy treatment is beneficial; and

7. Referrals for treatment for any identified risks or comorbid physical or psychiatric disorders, psychotherapy treatment, and treatment with medication.

3. Treatment Plan

After an appropriate mental health care provider has diagnosed the employee and made a determination of the above listed items, a treatment plan must be developed. Pursuant to Minn. R. 5221.6700, Subp. 4(A)(1)(a-d), a mental health provider must collaborate with the employee to establish a plan for treatment prior to commencing psychotherapy. The plan for treatment must provide the following:

1. Specify the treatment modality or modalities;

2. Identify if the treatment will be administered using telemedicine;

3. Assess the level of symptoms and functional status of the employee;

4. Develop specific goals for treatment;

5. Establish a timetable for achieving the treatment goals;

6. Prescribe the duration and frequency of treatment;

7. Address the plan to return to work; and

8. Provide necessary referrals.

Additionally, the mental health provider must provide education to the employee about PTSD and its treatment and provide any motivational interviewing needed to prepare the employee for trauma-focused therapy.

Once all three items above are completed: (1) a diagnosis is made; (2) an initial assessment completed; and (3) a treatment plan prepared, treatment for PTSD may be administered in the form of psychotherapy and/or medication.

Trauma-focused Psychotherapy Treatment

1. Psychotherapy Provider and Change of Provider

According Minn. R. 5221.6700, subp. 5(B), psychotherapy treatment for PTSD must be performed by a mental health care provider. The provider must be (a) trained to treat PTSD with each modality being used; and (b) have documentation of that training.

An employee may not change the mental health care provider who is providing psychotherapy more than once within the first 60 days of the employee’s first period of psychotherapy. After that, the employee may not change providers, except as provided by part 5221.0430. (Minn. R. 5221.6700, subp. 8). If approval is denied, a Medical Request may be filed.

2. Psychotherapy Modalities

Minn. R. 5221.6700, subp. 5(A) provides a list of multiple treatment modalities that fall under the allowable trauma-focused psychotherapy for PTSD. Pursuant to the rule, the treatment modalities may be used singularly, concurrently, or simultaneously. The modalities provided are as follows:

1. Cognitive behavioral therapy (CBT);

2. Cognitive processing therapy (CPT);

3. Cognitive therapy (CT);

4. Prolonged exposure therapy (PE)

5. Brief eclectic psychotherapy (BEP);

6. Eye-movement desensitization and reprocessing (EMDR);

7. Narrative exposure therapy (NET); and

8. Any other treatment modality recommended by the treating mental health care provider that is an evidenced-based, trauma-focused psychotherapy treatment modality.

3. Limits on Treatment

Minn. R. 5221.6700, subp. 5(B) limits treatment to no more than two times per week, “except to provide emergency treatment.” Furthermore, at least once every two weeks while psychotherapy is being administered, the psychotherapy provider must provide updates regarding the employee’s severity and changes of any PTSD symptoms. Updates must include a review of the treatment plan, goals, and adherence to the plan. Once reviewed, necessary adjustments to the treatment plan are to be made and an updated report of work ability submitted. (Minn. R. 5221.6700, subp. 5(C)).

Minn. R. 5221.6700, subps. 6 and 7, provide guidance on the duration of psychotherapy treatment allowed for PTSD.

A period of psychotherapy treatment begins with the first time a modality is initiated and ends 16 weeks later. Id.
If modalities are added during the 16 weeks, this does not extended the period of psychotherapy treatment.
However, there are no limits to the number of periods of psychotherapy that may be administered to an employee, so long as a medical provider determines an employee continues to meet the DSM-V criteria for PTSD and provided a complete psychological assessment, using objective testing is performed before the employee receives additional treatment, unless one of the following circumstances are met:

o A psychological assessment was completed within the previous year;

o Treatment was interrupted or delayed by the need to treat a different condition;

o Previous treatment did not meet the accepted standard of practice;

o There is documentation of all of the following during the last period of treatment:

~ Adherence to the treatment plan;

~ Decrease in PTSD symptoms;

~ Improvement in functional status; and

~ Further decrease in symptoms and continued improvement in functional status are anticipated with additional treatment.

o The employee has returned to work and needs treatment for an exacerbation of PTSD symptoms caused by their work activities; and

o In rare cases with exceptional circumstances (with approval after the filing of a Medical Request).

The psychotherapy provider must give notice of each additional period of treatment and each time a new treatment modality is added to psychotherapy.

4. Treatment with Medications

Medications may also be used to treat PTSD. Pursuant to Minn. R. 5221.6700, subp. 9, before prescribing medication for PTSD, a health care provider must evaluate whether the employee would benefit from psychotherapy treatment.

Furthermore, the rule provides that the initial prescription of a medication is limited to no more than three months with subsequent refills of the same medication limited to no more than six months per refill. Id. at subp. 9(d)(4). Medications are not to be prescribed in excess of the manufacturer’s maximum daily dosage and are to be prescribed in a generic formulation, if available.

The health care provider must prescribe only the following medications for the initial treatment of PTSD:

Selective serotonin reuptake inhibitors (SSRIs);
Selective norepinephrine reuptake inhibitors (SNRIs); and
Antihypertensive medication, if there is peer-reviewed scientific literature demonstrating the medication is effective treatment for PTSD.

If the above three categories of medications are contraindicated, produce undesirable side effects, or do not decrease the severity of symptoms, the provider may prescribe:

Serotonin antagonist and reuptake inhibitors (SARIs); and
Other medications if prescribed or recommended by a licensed psychiatrist, a psychiatric mental health advanced practice registered nurse (PMH-APRN) or another health care provider after consultation with a psychiatrist or PMH-APRN.

The provider may not prescribe benzodiazepines for treatment of PTSD.

Notice Requirements

1. Provider Requirements

Providers must give prior notice to a payer seven (7) working days before either beginning an additional period of psychotherapy treatment or treating a patient with an evidence-based, trauma-focused psychotherapy treatment modality other than those listed in the rules (noted above).
Prior notice must include: