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Medical Treatment Information

"Within one working day after an employee files a claim form under Section 5401, the employer shall authorize the provision of all treatment, consistent with Section 5307.27 (the state's medical treatment utilization schedule) or the American College of Occupational and Environmental Medicine's (ACOEM) Occupational Medicine Practice Guidelines, for the alleged injury and shall continue to provide the treatment until the date that liability for the claim is accepted or rejected in the 90 day discovery period. Until the date the claim is accepted or rejected, liability for medical treatment shall be limited to ten thousand dollars ($10,000) payable by the workers' compensation insurance carrier."

ACOEM GUIDELINES

In the past the state did not have official guidelines for medical treatment. Generally, workers have been entitled to treatment that is reasonable, necessary and related to the industrial injury. In the 2003 reforms, the state has adopted the ACOEM guidelines promulgated by the American College of Occupational and Environmental Medicine. Now treatment "reasonably required to cure or relieve the injured workers from the effects of his or her injury" has been defined by Labor Code 4600(b) to mean treatment that is based upon ACOEM. The ACOEM guidelines are now under Labor Code 4604.5 "presumptively correct on the issue of extent and scope of medical treatment."

Can doctors use treatments not covered by ACOEM? Under Labor Code 4604.5(a) ACOEM "may be controverted by a preponderance of the scientific medical evidence establishing that a variance from the guidelines is reasonably required to cure or relieve the injured worker from the effects of his or her injury"

UTILIZATION REVIEW

The 2003 reforms empowered insurers to set up utilization review (UR). UR procedures of a carrier are to be provided upon request. Nothing in law requires a claims examiner to use UR before authorizing a doctor's treatment recommendations, but use of UR is at the insurer's option. Most UR procedures allow for some in-house appeal if the treating doctor wants to contact the UR physician to discuss the case.

What are the UR time frames? For the vast majority of medical treatments, the UR time frame is set forth in Labor Code 4610(g). The doctor must request authorization in writing and submit the treatment request along with the current treatment report and the required Request for Authorization (RFA) form. A UR decision is to be made within 5 to 14 working days from the date of the medical treatment recommendation and communicated to the primary treating physician, the requesting doctor and injured worker in writing within 2 business days.

Must UR explain any recommendations to deny treatment certification? Labor Code Section 4610(g)(4) says that when a response to a request for treatment is to modify, delay, or deny it "shall include a clear and concise explanation of the reasons for the decision, the criteria or guidelines used, and the clinical reasons for the decision".

If treatment is denied by UR, the injured worker must request an Independent Medical Review within 30 days of the denial. If this is not done, the UR determination of treatment prevails for one year.

LIMITATION ON CERTAIN TREATMENTS

For injuries after January 1 2004, the insurer is not required to provide for each injury more than 24 chiropractic treatments, 24 physical therapy sessions, and 24 occupational therapy visits. These limits do not apply to visits after a surgery when they are based on a postsurgical treatment utilization schedule.

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