Who can we certify?

This is a generic description of our guidelines, and there are variations from state to state.

There has to be evidence of seeking diagnosis and care outside of looking for marijuana certification, or there has to be clear evidence of the physical condition itself through imaging or physical exam.

Bottom line: If they have records that are proof of a chronic qualifying diagnosis from any time in the past, with documentation of some treatment having been tried (successfully or unsuccessfully), they will qualify, year after year, with the same records, without extended visits.

Examples:

  • Patient with records from a doctor of any kind (except they can’t be from a certification doctor) with a typically unresponsive diagnosis and some evidence of treatment on it/them will qualify year after year without extended visits.
  • This includes:
    • Migraines
    • Degenerative Disk Disease
    • Fibromyalgia
    • Arthritis
    • CRPS
    • Any chronic severe pain where there is evidence of longstanding pain and resistance to treatment.
  • This does not include other certification visit notes. The certification cannot be based on other certifications. It has to be based on 1) Evidence of seeking diagnosis and/or care outside of marijuana certification, or  2) Physical evidence of the condition itself, in physical exam or imaging.
    • However, if there is evidence of adequate physical exam being done in a certification center, and that physical exam can be corroborated, then the past certification is proof of chronicity.
  • It is best if the patient can get the records to the doctor prior to the visit as it might prevent a visit without adequate records. If the patient does not bring in the records, the doctors can refrain from submitting the certification until records are reviewed.

When do we need an extended visit?

If there is only circumstantial or no proof of the condition, and the doctor needs to do some probing to decide if it is a real condition or not, or that the cause could be something serious that has not been adequately ruled out, there will need to be an extended visit.

Examples:

  • Patient stating 10 yr back pain treated with massage and ibuprofen but no records for a cause: Dr. will need an extended visit to do a physical exam and order an x-ray to rule out bone cancer.
  • Patient stating they have AIDS / Hep C but no records: Dr. will need to take a history and order a blood test to confirm. They can submit the cert in the extended visit, but if the test is negative, we will call the AZDHS to rescind the certification.
  • Any pain that is not well documented. This includes if there is a chart note stating pain, but severity, duration, and treatment are not clearly discussed, and there is no diagnostic imaging like an x-ray with positive signs. THe doctor will need to take the extended visit time to evaluate, and possibly refer or order imaging.

Receptionists will ask what they are seeking the certification for. If the patient is willing to share, the team should be able to inform patient whether or not they would meet state requirements
i.e., not for depression, anxiety, insomnia, etc…

  • If they are seeking a certification for one of the serious chronic illness diagnosis, do they have any medical record history of that diagnosis? (AIDS, HIV, ALS, Crohn’s, Agitation of Alzheimer’s, Cancer, Glaucoma, Hepatitis C, PTSD)
    • If they do not have medical records, we may not be able to help them with certification
    • If the diagnosis is AIDS, HIV, or Hepatitis C, we can do an extended visit and order lab tests to confirm and then certify
    • For the other diagnosis, we would need to see confirming medical records
    • For PTSD, the patient still needs to show that they are in active treatment/counseling. This should not change from what is already happening.
  • For cachexia or wasting
    • We may be able to do with an extended appointment but laboratory testing may be required.
    • We cannot just rely on records from the past to certify.
    • We would need to establish a history and reason for this condition
  • Severe and Chronic Pain
    • If patient has seen a physician within the past 12 months, please ask them to produce records (if available) for evaluation by the doctor.
    • If patient has an obvious injury or malformation, evaluation during certification only should be sufficient
    • If patient denies seeing a physician within the past 12 months, does not have past medical records or refuses to send in medical records, then they would need to be scheduled for the extended appointment.
      • It is important that patient is informed at the time of scheduling that there is no guarantee that they will be certified and that they may be required to complete x-rays, MRIs or other testing to confirm diagnosis.
      • This is the time to educate patient on the importance of complying because the physician has the right to pull the certification if they do not comply.
      • If patient has been seeing a chiropractor, massage therapist, acupuncturist, etc.. and the diagnosis is one that meets certification (they must provide records to confirm) we will be able to certify without the extended visit
  • Severe Nausea
    • This is difficult and one that I feel we will need records of proof for certification.
    • This will definitely be a case by case situation and patient would need to be made aware that there may be testing required for evaluation

 

  • Seizures, including epilepsy characteristics
    • This diagnosis absolutely needs records with proof from an outside physician
    • Records can be past the 12-month period depending on what is said in the notes (history).
    • Records will need to be submitted for evaluation
  • Severe or persistent muscle spasms, including those characteristic of multiple sclerosis
    • We would like to see medical records with proof of diagnosis here as well
    • Can be past the 12-month period, again depending on what is said in the notes (history).
    • Records will need to be submitted for evaluation   

 

What are the main things the doctor has to do?

  1. The Doctor can diagnose and treat (including certify) in the same visit, as long as they can do a good job of supporting their diagnosis in the chart AND provide a reasonable care protocol around the diagnosis, that may or may not include Medical Marijuana.
  2. Medical records from anywhere (Chiropractic, Massage, etc) OR that are older than 12 months are fine to support a diagnosis, but if conventional medical records regarding the approved diagnosis are NOT available, the Doctor has to diagnose based on the history, whatever records there are, physical exam, and/or testing, as required by the specific diagnosis, and provide a reasonable plan based on the diagnosis.
  3. If  the patient says there are records available regarding the approved condition from within the last 12 months from a conventional medical provider and is willing to fill out a Record Request, we HAVE to see the records before certifying the patient.
    1. However, if the diagnosis is justifiable even though there are no records from within the last 12 months from a conventional medical provider or if the patient refuses to fill out a Records Request, the Doctor can safely initial the section “Have reviewed the qualifying patient’s medical records, including medical records from other treating physicians from the previous 12 months…”
  4. The Doctor can certify a patient based on history and exam AND request further testing if needed, but if the patient does not comply with diagnostic procedures that you require for the diagnosis and certification within a period of time, or testing needed to confirm is negative, we must contact the Medical Marijuana Department to revoke the card, and certainly should not recertify.
  5. Any medical record(s) from another provider used to confirm or support the diagnosis used to certify the patient for Medical Marijuana needs to be in the chart. It doesn’t have to be every record, it just has to be that the chart must be able to stand on its own as a testament to the validity of the certification.

 

Examples:

  1. Veteran with missing limb or patient with surgical implants or large visible surgical scars refusing to contact the VA for records:
  2. The Doctor can diagnose pain and certify, as long as some other therapy (NSAIDS, massage, etc) had been tried, and there is no reason to suspect another condition like bone cancer causing the pain.
  3. Chronic back pain patient with chiropractic records every week and not seeing results:
  4. The Doctor can certify, but must also require an x-ray to rule out more serious conditions like Degenerative Disk Disease or bone cancer. Because the pain is obvious from treatment history and exam, you do not have to require the patient get the x-ray to certify, but you must order the x-ray to provide adequate medical care.
  5. Patient claims chronic disk disease and claims to have tried various therapies, but has no records or refuses to fill out Records Request, physical exam is non-confirmative:
  6. If the Doctor genuinely believes the patient, they can certify, but must require an x-ray or any appropriate diagnostic procedure be completed in a specific period of time (say 1 month,) to confirm the diagnosis.  If the calendar reminder pings one month later and no imaging is on your desk, we have to call the patient to say “Because your card is based on the diagnosis, and we require the x-ray to confirm the diagnosis, if you don’t get the x-ray this week, we will be forced to revoke your card.” Chart this conversation and follow through.
  7. Patient with knee pain for 4 months, no records, physical exam is positive for pain on palpation of MCL but no history of any treatment or medical care:
  8. This patient should not have made it into the Doctor’s schedule. The patient has to have tried something else first, and/or have sought a diagnosis elsewhere. A simple MCL strain is not a reason to give a patient a year of unrestricted 12 month access to a controlled substance when some time and massage might just clear it up.
  9. A patient with what looks like undiagnosed Melanoma on their back:
  10. This patient needs diagnosis and probably surgery, and Medical Marijuana offered before a diagnosis will not look like prudent care. It looks like the cart before the horse. The Doctor must provide a derm or oncology referral. THe Doctor can tell the patient that they will fill the paperwork, and if they get diagnosed adequately the Doctor will submit the paperwork and certify them. If they refuse diagnosis or standard medical care, and say they want to treat it with bloodroot and cannabis, The Doctor must still provide the referral, and if they plan to certify them, the Doctor should get an “Against Medical Advice” form signed by the patient.
  11. A patient diagnosed with cancer who is refusing oncology care, has not seen an MD in over a year, but has older records:
  12. The Doctor can provide certification.
  13. Patient with uncontrolled glaucoma with bloodshot bulging sclera:
    Immediate trip to ER is in order, not certification. Once the emergency is abated, cannabis is an option. If the Doctor certifies the patient in this exam, it would not look good. The Doctor always has to do what is medically prudent.