WSIA

From the Department of Labor & Industries:

New state law’s ‘medically appropriate’ provision took effect June 11

A provision of new legislation, which expands the criteria for approving medical treatment for injured workers, took effect on June 11, 2026.

Engrossed Second Substitute Senate Bill (E2SSB) 5847, was passed by the Legislature as part of the 2025-26 session.

It modifies Revised Code of Washington (RCW) 51.36.010, which required network providers to follow L&I’s evidence-based coverage decisions and treatment guidelines and policies, as well as follow other national treatment guidelines, when seeking medical treatment for injured workers.

With the legislation’s new language, those requirements must still be followed, but exceptions may be made if the medical treatment being sought is considered to be medically appropriate.

In general, L&I evidence-based guidelines, coverage decisions, and policies already are medically appropriate.

These evidence-based guidelines, coverage decisions, and policies are safe and effective, and include the findings of the Industrial Insurance Medical Advisory Committee (RCW 51.36.140), the Industrial Insurance Chiropractic Advisory Committee (RCW 51.36.150), the Washington state Health Technology Clinical Committee (RCW 70.14.090-70.14.120), and the Washington state Pharmacy and Therapeutics Committee.

Requests for procedures not covered by the evidence-based guidelines, coverage decisions, or policies may be medically appropriate when the following criteria are met:

• The requested service is safe and effective, and,
• Relevant individual circumstances and characteristics of the worker are not addressed by existing evidence-based guidelines, coverage decisions, or policies. Also, the plan of care is consistent with the symptoms and diagnosis of the worker’s condition, and is at least as beneficial as existing or available alternatives.

The treatment may also be approved in an emergency situation exists that is unable to be prospectively addressed by evidence-based guidelines, coverage decisions, or policies.

L&I will evaluate requests for treatment that do not align with L&I’s coverage decisions and treatment guidelines and policies, and other national treatment guidelines.

If a worker or provider disagrees with a treatment decision made by a self-insurer, L&I will resolve the dispute by order.

The approved legislation includes several other changes that affect the authorization of treatment under claims. Most of the changes will not take effect until Jan. 1, 2028.

Questions? Email: SITrainerQuestions@Lni.wa.gov