Voglio sapere a riguardo di…

38922

Federal Register / Vol. 86, No. 139 / Friday, July 23, 2021 / Rules and Regulations
musculoskeletal disorder meets the requisite severity for the listing.
Our use of the consecutive 4-month proximity of time requirement is also consistent with the standard recognized by the Veterans Health Administration VHA and Department of Defense DoD, as set out in their clinical practice guidelines.13 For example, the VHA and DoDs Clinical Practice Guideline for the Management of Medically Unexplained Symptoms:
Chronic Pain and Fatigue directs initial revisits at 2 to 3 week intervals, with visits every 3 to 4 months once the patient is doing well.14 Similarly, the VHAs and DoDs Clinical Practice Guideline for Diagnosis and Treatment of Low Back Pain describes the duration of time for intervention, based on a systematic review, as requiring a minimum follow-up for effectiveness of 12 weeks and recommends monthly reassessment after initiation of therapy if low back pain continues and no serious specific underlying cause of low back pain is found.15

khammond on DSKJM1Z7X2PROD with RULES

Rationale for This Rule As noted above, on January 31, 2020, the Secretary of Health and Human Services declared COVID19 a national public health emergency. The COVID
19 national public health emergency has dramatically changed the provision of, and access to, healthcare services throughout the country. Individuals with musculoskeletal impairments who, before the national public health emergency, would seek and receive healthcare at a frequency consistent with the standards cited above, now might be unable or choose not to seek care in the same manner and frequency.
This is due in part to healthcare organizations and government agencies such as the Centers for Medicare &
Medicaid Services CMS 16 prioritizing the most urgent services and 13 85 FR at 78169 n.38 citing Veterans Health Administration & Department of Defense. 2001.
VHA/DoD Clinical Practice Guideline for the Management of Medically Unexplained Symptoms:
Chronic Pain and Fatigue. https
www.healthquality.va.gov/guidelines/MR/mus/
mus_fulltext.pdf.
14 Id.
15 85 FR at 7816970 citing Veterans Health Administration & Department of Defense. 2017.
VA/DoD Clinical Practice Guideline for Diagnosis and Treatment of Low Back Pain. https
www.healthquality.va.gov/guidelines/Pain/lbp/
VADoDLBPCPG092917.pdf.
16 Centers for Medicare & Medicaid Services CMS Recommendations: Re-opening Facilities to Provide Non-emergent Non-COVID19 Healthcare https www.cms.gov/files/document/covidrecommendations-reopening-facilities-provide-nonemergent-care.pdf; see also Non-Emergent, Elective Medical Services, and Treatment Recommendations https www.cms.gov/files/document/cms-nonemergent-elective-medical-recommendations.pdf.

VerDate Sep<11>2014

15:54 Jul 22, 2021

Jkt 253001

encouraging patients to delay other procedures during the pandemic. For example, the North American Spine Society NASS provided guidance for delaying non-emergent procedures for people with chronic spinal conditions.17
Likewise, many individuals have delayed or deferred important treatment due to closures of medical offices, fears of contracting COVID19 infection including having a high risk individual in the household, and other challenges created or exacerbated by the pandemic, such as difficulty accessing transportation. According to one source, among the general U.S. population reporting delayed care for serious problems during the pandemic, 69%
cited nonfinancial access barriers, such as being unable to get an appointment, find a physician who would see them, or access the care location.18
Additionally, the National Center for Health Statistics estimated that 41% of U.S. adults had delayed or avoided medical care, including urgent or emergency care 12% and routine care 32% because of concerns about COVID19.19
We are also temporarily changing the consecutive 4-month close proximity of time rule to a consecutive 12-month rule because the manner of care provided changed throughout the COVID19
national public health emergency. To be responsive to this change in the manner of care, we instructed our adjudicators to temporarily hold claims that would benefit from the flexibilities in this rule, so we will process claims affected by this rule on or after the effective date of this rule. Due to safety concerns, many healthcare providers shifted to emphasizing or exclusively scheduling telehealth or virtual visits. The optimization of telehealth is consistent with the guidance issued by many specialist organizations, such as NASS,20 the American College of 17 https www.spine.org/Portals/0/assets/
downloads/Publications/NASSInsider/
NASSGuidanceDocument040320.pdf.
18 Delayed Care with Harmful Health ConsequencesReported Experiences from National Surveys During Coronavirus Disease 2019
Infectious Diseases JAMA Health Forum JAMA
Network. See also The Impact of Coronavirus on Households Across America https
cdn1.sph.harvard.edu/wp-content/uploads/sites/
21/2020/09/NPR-RWJF-Harvard-National-Report_
092220_Final1-4.pdf and COVID19: Experiences Among the Medicare Population https
www.cms.gov/files/document/medicare-currentbeneficiary-survey-covid-19-data-snapshot.pdf.
19 Reduced Access to Care: Household Pulse Survey National Center for Health Statistics https www.cdc.gov/nchs/covid19/pulse/reducedaccess-to-care.htm.
20 https www.spine.org/Portals/0/assets/
downloads/Publications/NASSInsider/
NASSGuidanceDocument040320.pdf.

PO 00000

Frm 00018

Fmt 4700

Sfmt 4700

Surgeons ACS,21 the American Academy of Orthopedic Surgeons AAOS,22 and the American College of Rheumatology ACR.23
Although many individuals access telehealth visits successfully, the clinical signs and findings required by some of the listings may not be present in the telehealth record due to the limitations of telemedicine. While testing by the patient is possible through telehealth, there are limits in provocative testing that is, testing that manipulates the areas where you have pain in order to reproduce the pain, discrete palpation that is, a technique that uses targeted pressure to identify and quantify the abnormalities of the musculoskeletal system, such as warmth, swelling, pain, tenderness, and trigger points, and strength or stability testing.24 During the beginning of the COVID19 pandemic, orthopedists created guidelines for virtual examinations of patients through telemedicine, and found that while the patient could perform many tests, there are inherent limitations to testing in this manner. For example, the authors recommend using another person to hold the camera during gait examination to get a better view of the patients gait mechanics, which is not always possible.25 Further, the VHA has found that although patients appreciate telehealth, many are unable to complete exams that require precise measurements, such as range of motion or reflexes.26
Consequently, disability claimants with musculoskeletal disorders of the severity required by the listings who would have been able to provide evidence that their musculoskeletal disorder met the consecutive 4-month close proximity of time requirement 21 COVID19 Guidelines for Triage of Orthopaedic Patients https www.facs.org/covid19/clinical-guidance/elective-case/orthopaedics.
22 Navigating the COVID19 Pandemic https
www.aaos.org/globalassets/about/covid-19/aaosclinical-considerations-during-covid-19.pdf.
23 COVID19 Clinical Guidance for Adult Patients with Rheumatic Diseases https
www.rheumatology.org/Portals/0/Files/ACRCOVID-19-Clinical-Guidance-Summary-Patientswith-Rheumatic-Diseases.pdf.
24 Tanaka et al. 2020. Telemedicine in the Era of COVID19: The Virtual Orthopaedic Examination. The Journal of Bone and Joint Surgery, Incorporated, 00:e1 17 http dx.doi.org/
10.2106/JBJS.20.00609.
25 Laskowski, et al. 2020. The Telemedicine Musculoskeletal Examination. Mayo Clinic Proc.
958 https www.ncbi.nlm.nih.gov/pmc/articles/
PMC7395661/.
26 Baus, Shanna, PAC. Telehealth & Disability Items: Veterans Health Administration.
Presentation to the Standing Committee of the National Academies of Science and Medicine Health and Medicine Division, on December 1, 2020.

E:FRFM23JYR1.SGM

23JYR1