New (non-established) or emerging treatments and services policy

Background

WorkCover Queensland decisions regarding treatments and services are guided by the:

• Medical Services Advisory Committee (MSAC)
• Medicare Benefits Schedule (MBS)
• Prostheses List Advisory Committee (PLAC)
• Prescribed List of Medical Devices and Human Tissue Products
• Pharmaceutical Benefits Advisory Committee (PBAC)
• Pharmaceutical Benefits Schedule (PBS)
• Australian Register of Therapeutic Goods (ARTG)
• evidence-based medicine (i.e. research papers, literature reviews, published guidelines and other valid external sources).

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

What WorkCover will pay for:

WorkCover will consider paying the reasonable costs of new (non-established) 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 WorkCover, the requesting practitioner must provide strong clinical evidence of the safety and efficacy of the new (i.e. non-established) or emerging treatments and services.

New (non-established) or emerging treatments and services can be paid under the Workers’ Compensation and Rehabilitation Act 2003 (the legislation), when WorkCover considers:

• the treatment or service is reasonable and necessary to treat the accepted work-related injury, and
• the cost of the treatment or service is reasonable.

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

• NHMRC levels of evidence and grades for recommendations for developers of guidelines
• the relevant WorkCover Medical Table of Costs
• the relevant WorkCover surgical guidelines (e.g. Upper limb, Lower limb, Spinal, Pain interventions)
• other related WorkCover guides:
• Treatment and approvals
• Approved registered providers
• Mental Injury Treatment Guidelines.

NHMRC: Resources for guideline developers

NHMRC is currently working with an expert advisory committee to develop an online resource for guideline developers that will update NHMRC’s current Guide to the development, evaluation and implementation of clinical practice guidelines and accompanying handbooks.

Definitions

In this policy, new (non-established) 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 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 WorkCover policies.

Frequently asked questions (FAQs) in relation to new (non-established) or emerging treatments and services