UTILIZATION REVIEW ("UR"): [ ABCs | CCR 9792.9 | CCR 9792.8 | LC 4610 | UR REPORT REQUIREMENTS | LC 4604.5 | SB 228 | SB 899 | ACOEM is it | When ACOEM don't APPLY | Not Mandatory | Time Deadlines | Sevice Methods | Sandhagen | Objection Letter Requirements | Not Evidence concering AOE/COE treatment | Only Chiro UR Doc assesses Chiro Tx | REQUEST PANEL QME | OTHER EBM | Spiel ]
WARNING: THE BELOW SUGGESTIONS, INFORMATION AND RESEARCH PASSAGES ARE FOR EDUCATIONAL PURPOSE ONLY AND ARE NEITHER TO BE CONSTRUED AS LEGAL ADVICE NOR ANY GUARANTEE THAT YOU WILL GET YOUR BILLS PAIDS. USE THIS PAGES CONTENTS AT YOUR OWN RISK. |
ABC'S OF UR: [ CCR 9792.9 (b)(1) ]
After receipt of the "prospective" [on time] Request for Authorization, the CA has "five working days" to (1) authorize, modify, or deny the treatment [CCR 9792.9 (b)(1)] or (2) request reasonable additional information in order to render a decision, which delays to authorization [9792.9 (b)(2)]. A decision to delay or modify a request for authorization must be communicated to the injured worker, the PTP, and applicant attorney via fax or phone within "24 hours" of the decision [9792.9 (b)(4)]. Then, the decision must be reduced to writing and served upon the same group of people within "two business days." [9792.9 (b)(4)]
If the CA can not meet the five working-day time dead-line to authorize, modify, or delay a prospective request for authorization secondary to (1) needing more information for the PTP, or (2) needing a "specialized consult" by an "expert reviewer," i.e., UR, then she/he MUST "immediately notify" the PTP, injured worker, and applicant attorney "in writing" of "the specialty of the expert reviewer" to be consulted. [9792.9 (g)(2)] [So, technically in order to even use the UR doctor, the claims administrator must immediately notify the PTP and patient of the specialty of the UR doctor needed…. I’ve yet to see this happen.]
CCR 9792.10 (a)(1): If the request for authorization of medical treatment is not approved, or if the request for authorization for medical treatment is approved in part, any dispute shall be resolved in accordance with Labor Code section 4062.
CCR 9792.10 (a)(2): An objection to a decision disapproving in whole or in part a request for authorization of medical treatment, must be communicated to the claims administrator by the injured worker or the injured worker's attorney in writing within 20 days of receipt of the utilization review decision. The 20-day time limit may be extended for good cause or by mutual agreement of the parties.
CCR 9792.9 (b) The utilization review process shall meet the following timeframe requirements:
(1) Prospective or concurrent decisions shall be made in a timely fashion that is appropriate for the nature of the injured worker's condition, not to exceed five (5) working days from the date of receipt of the written request for authorization.
(2) If appropriate information which is necessary to render a decision is not provided with the original request for authorization, such information may be requested by a reviewer or non-physician reviewer within five (5) working days from the date of receipt of the written request for authorization to make the proper determination. In no event shall the determination be made more than 14 days from the date of receipt of the original request for authorization by the health care provider.
(A) If the reasonable information requested by the claims administrator is not received within 14 days of the date of the original written request by the requesting physician, a reviewer may deny the request with the stated condition that the request will be reconsidered upon receipt of the information requested.
"The ACOEM Guidelines were adopted as a standard of utilization review in workers’ compensation cases in Senate Bill 228 which took effect on January 1, 2004. Senate Bill 899 later incorporated the ACOEM Guidelines into the statutory definition of medical treatment reasonably required to cure or relieve from the effects of an industrial injury. The Guidelines do not cover all types of injuries and medical conditions. However, where they do apply, they have been given a presumption of correctness that can only be rebutted by more persuasive scientific evidence.
The ACOEM Guidelines were not written for the purpose of serving as utilization review standards. Rather, they were intended as practice guidelines for occupational physicians to promote not just the least expensive treatment, but rather the most effective treatment in terms of minimizing disabilities and facilitating a prompt return to work." WCJ Foust 2005.
Title 8 CCR section 9792.8 (a) mandates the the ACOEM guidelines are to be used by the insurers utilization review. More explicitly, said regulation states:
| CCR 9792.8 (a) (1): "the criteria or guidelines used in the utilization review process shall be consistent with the American College of Occupational and Environmental Medicine's (ACOEM) Practice Guidelines, Second Edition. The guidelines set forth in the ACOEM Practice Guidelines shall be presumptively correct on the issue of extent and scope of medical treatment until the effective date of the utilization schedule adopted pursuant to Labor Code section 5307.27. The presumption is rebuttable and 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." |
However, CCR 9792.8 (a) (2) allows for "other evidence-based medical treatment guidelines" to be used in cases where "conditions" are not addressed by ACOEM. More explicitly, said subsection states:
| CCR 9792.8 (a) (2): For all conditions or injuries not addressed by the ACOEM Practice Guidelines or by the official utilization schedule after adoption pursuant to Labor Code section 5307.27, authorized treatment shall be in accordance with other evidence-based medical treatment guidelines that are generally recognized by the national medical community and are scientifically based. Treatment may not be denied on the sole basis that the treatment is not addressed by the ACOEM Practice Guidelines until adoption of the medical treatment utilization schedule pursuant to Labor Code section 5307.27. After the Administrative Director adopts a medical treatment utilization schedule pursuant to Labor Code section 5307.27, treatment may not be denied on the sole basis that the treatment is not addressed by that schedule. |
In 2005, an en banc WCAB decision (Sandhagen vs. Cox & Cox Construction II (2005) 70 CCC 208) stated the following:
"for these reasons, among others, we will not insert into section 4610 language that the Legislature has not included, i.e., a requirement that utilization review must be used in every case. Pursuant to section 4610, a defendant has discretion to undertake or not undertake utilization review with respect to any particular proposed medical treatment." |
Also, the commissioners stated the forthcoming in the WCAB En banc opinion of Simmons vs. SCIF:
"For the guidance of the workers’ compensation community, we reiterate that a defendant is not required to undertake utilization review in every case. (Sandhagen v. Cox & Cox Construction, Inc. (2005) 70 Cal.Comp.Cases 208 (Appeals Board en banc).) Accordingly, if a defendant believes at the time a treating physician prescribes treatment that there is or may be an issue of whether the proposed treatment for an admitted body part is causally related to the industrial injury, the defendant may elect to bypass utilization review and, instead, timely initiate the AME/QME procedures of section 4062(a). If the defendant does elect to undertake utilization review, however, it must complete that utilization review within the deadlines mandated by section 4610. (Sandhagen v. Cox & Cox Construction, Inc., supra, 69 Cal.Comp.Cases 1452.) "
2) UR TIME DEADLINES: UR MUST follow the time-deadlines cast by Labor Code section 4610(g)(1) and, more importantly, Title 8 CCR section 9792.9.
A) The ER only has 5 days to respond to a proper (with all information) request for authorizaion:
Title 8 CCR section 9792.9 (b)(1) states, in pertinent part:
"Prospective or concurrent [UR] decisions shall be made in a timely fashion that is appropriate for the nature of the injured worker's condition, not to exceed five (5) working days from the date of receipt of the written request for authorization." |
Now, ONLY if more information is needed and request with 5 days, then the insurer has 14 days to make the decision. More explicitly, Title 8 CCR section 9792.9 (b) (2) states, in pertinent part:
"If appropriate information which is necessary to render a decision is not provided with the original request for authorization, such information may be requested by a reviewer or non-physician reviewer within five (5) working days from the date of receipt of the written request for authorization to make the proper determination. In no event shall the determination be made more than 14 days from the date of receipt of the original request for authorization by the health care provider." |
The insurer has some ways to escape these deadlines (see CCR 9792.9 (g) (1) ), but this escape also if filled with requirements - see CCR 9792.9 (g) (2).
3) The WCAB Speaks: Sandhagen vs. SCIF I
In 2004, an en banc WCAB decision (Sandhagen vs. Cox & Cox Construction I (2004) 69 CCC 1452) mandated that if UR is not performed within 14 days of receipt of the medical request for authorization, that report is worthless and can NOT be forwarded to a QME or AME. Here's the exact verbiage from these decisions:
"(1) The utilization review time deadlines of section 4610(g)(1) are mandatory and, if a defendant fails to meet these mandatory deadlines, it is precluded from using the utilization review procedure for the particular medical treatment dispute in question; (2) If a defendant undertakes an untimely utilization review procedure, any utilization review report obtained as to the particular treatment in dispute is not admissible in evidence, and any utilization review report obtained cannot be forwarded to an AME or QME if section 4062(a) procedures are timely pursued; and (3) When a defendant does not meet the section 4610(g)(1) deadlines, it may use the procedure established by section 4062(a) to dispute the treating physician’s treatment recommendation; however, the defendant (not the applicant) is then the “objecting party” and the defendant must meet the section 4062(a) deadlines, unless those deadlines are extended for good cause or by mutual agreement." |
4) Objection Letter Requirements: CCR 9792.9 (j), (k) & (l) speak for themselves:
CCR 9792.9 (j) A written decision modifying, delaying or denying treatment authorization under this section shall be provided to the requesting physician, the injured worker, and if the injured worker is represented by counsel, the injured worker's attorney and shall contain the following information: (1) The date on which the decision is made. (2) A description of the specific course of proposed medical treatment for which authorization was requested. (3) A specific description of the medical treatment service approved, if any. (4) A clear and concise explanation of the reasons for the claims administrator's decision. (5) A description of the medical criteria or guidelines used pursuant to section 9792.8, subdivision (a)(3). (6) The clinical reasons regarding medical necessity. (7) A clear statement that any dispute shall be resolved in accordance with the provisions of Labor Code section 4062, and that an objection to the utilization review decision must be communicated by the injured worker or the injured worker's attorney on behalf of the injured worker to the claims administrator in writing within 20 days of receipt of the decision. It shall further state that the 20-day time limit may be extended for good cause or by mutual agreement of the parties. The letter shall further state that the injured worker may file an Application for Adjudication of Claim and Request for Expedited Hearing, DWC Form 4, showing a bona fide dispute as to entitlement to medical treatment in accordance with sections 10136(b)(1), 10400, and 10408. (8) Include the following mandatory language: Either "If you want further information, you may contact the local state Information and Assistance office by calling [enter district I & A office telephone number closest to the injured worker] or you may receive recorded information by calling 1-800-736-7401. or "If you want further information, you may contact the local state Information and Assistance office closest to you. Please see attached listing (attach a listing of I&A offices and telephone numbers) or you may receive recorded information by calling 1-800-736-7401." and "You may also consult an attorney of your choice. Should you decide to be represented by an attorney, you may or may not receive a larger award, but, unless you are determined to be ineligible for an award, the attorney's fee will be deducted from any award you might receive for disability benefits. The decision to be represented by an attorney is yours to make, but it is voluntary and may not be necessary for you to receive your benefits." In addition, the non-physician provider of goods or services identified in the request for authorization, and for whom contact information has been included, shall be notified in writing of the decision modifying, delaying, or denying a request for authorization that shall not include the rationale, criteria or guidelines used for the decision. (9) Details about the claims administrator's internal utilization review appeals process, if any, and a clear statement that the appeals process is on a voluntary basis, including the following mandatory statement: "If you disagree with the utilization review decision and wish to dispute it, you must send written notice of your objection to the claims administrator within 20 days of receipt of the utilization review decision in accordance with Labor Code section 4062. You must meet this deadline even if you are participating in the claims administrator's internal utilization review appeals process." k) The written decision modifying, delaying or denying treatment authorization provided to the requesting physician shall also contain the name and specialty of the reviewer or expert reviewer, and the telephone number in the United States of the reviewer or expert reviewer. The written decision shall also disclose the hours of availability of either the reviewer, the expert reviewer or the medical director for the treating physician to discuss the decision which shall be, at a minimum, four (4) hours per week during normal business hours, 9:00 AM to 5:30 PM., Pacific Time or an agreed upon scheduled time to discuss the decision with the requesting physician. In the event the reviewer is unavailable, the requesting physician may discuss the written decision with another reviewer who is competent to evaluate the specific clinical issues involved in the medical treatment services. (l) Authorization may not be denied on the basis of lack of information without documentation reflecting an attempt to obtain the necessary information from the physician or from the provider of goods or services identified in the request for authorization either by facsimile or mail. |
5. UR may NOT be used as evidence to support AOE/COE: Simmons vs. SCIF (2005) 70 CCC 866 WCAB En Banc, in pertinent part, Simmons states:
"A utilization review physician’s report is not admissible for the purpose of determining whether the industrial injury caused or contributed to the need for a particular treatment, i.e., a utilization review physician may address only the issue of whether a particular treatment is medically necessary..."
And:
"Although the ACOEM guidelines are “presumptively correct on the issue of extent and scope of medical treatment” (Lab. Code, §4604.5(c) (emphasis added)), they are not presumptively correct on the issue of whether a need for medical treatment is causally related to the industrial injury."
[ Chiro on Chiro | Time Dead-lines |
Title 8 CCR §9792.6 (9-22-05 ) Definitions (including prospective, retrospective, and Request for authorization)
Labor Code §4610 Main Rules
#5) LC4610(e): CHIRO ON CHIRO (see also CCR 9792.9 (f))
Only a Chiropractor may perform a Utilization Review (UR) upon another Chiropractor, and a Chiropractor UR doctor may NOT comment upon a MD's opinions:
"No person other than a licensed physician who is competent to evaluate the specific clinical issues involved in the medical treatment services, and where these services are within the scope of the physician's practice, requested by the physician may modify, delay, or deny requests for authorization of medical treatment for reasons of medical necessity to cure and relieve." Here's the whole Labor Code: 4610.
09-20-05 XXX Insurance
Dear Ms. CA and Ms. RN: The patient and I have received Ms. RN's letter dated 09-12-05 in which she has modified and “delayed” my original treatment plan (which was faxed to you in my DFR on 09-03-05). I object to this determination based on Labor Code 4610(e), which states the following: “No person other than a licensed physician who is competent to evaluate the specific clinical issues involved in the medical treatment services, and where these services are within the scope of the physician's practice, requested by the physician may modify, delay, or deny requests for authorization of medical treatment for reasons of medical necessity to cure and relieve.” Therefore, this facsimile / letter shall serve as our objection per Labor Code 4062(a) and IMC form 106 (Request for Qualified Medical Evaluator) is hereby requested immediately – again per 4062(a). If we do not receive this within 5 days, we shall file our own QME request form with the DWC Medical unit per Labor Code section 4062.1 (b). I may add that a proper UR Review should have been completed by a licensed Chiropractor by no later than 09-17-05 (14 days after your receipt of my DFR) and any subsequent attempts at UR on this matter are non-allowable / non-admissible per Sandhagen Vs. SCIF I (2004) 69 CCC 1452 WCAB en banc. Sincerely,
Dr. Douglas M. Gillard, DC, IDE, IME, QME
cc: Patient DMG:dmg |
REQUEST PANEL QME: [ 4062 | 4060 | 4061 ]
If the insurer objects to any PTPs medical determination, and the IW is not represented by an Attorney, then the patient may object to the ICs determination and file a IMC-106 with the DWC Medical Unit which starts the Panel QME process. Here's a copy of this form: (IMC-106)
SCIP DWC - Medical Unit Dear Claims administrator: I have reviewed the recent UR denial with the patient and he/she objects to this determination. At this time, per Labor Code section 4062 (a), please forward this unrepresented patient IMC form 106, so the panel QME process may begin. If the patient does not receive this form within 5 days, I shall assist him/her in filing the form ( IMC form 106 - "Request for Qualified Medical Evaluator" )with the DWC-medical unit, which is allowed per Labor Code section 4062.1 (b). Note: this objection has been made within the 20-day mandated time-frame per LC4062(a). If you wish to avoid this costly and unnecessary adventure, I suggest that you authorized the requested XXXXXXXXXX immediately as my previous request for authorization was fully supported by ACOEM. Sincerely,
Dr. Douglas M. Gillard, DC, IDE, QME |
UR REPORT TIME DEAD-LINES: [Labor Code: 4610(g) and 4610(g)(1)]
Prospective review: Here's the definition per CCR 9792.6(n) "Prospective review" means any utilization review conducted, except for utilization review conducted during an inpatient stay, prior to the delivery of the requested medical services." The UR department has 14 days to make a determination per Labor Code §4610(g) and Sandhagen vs. SCIF I (69 CCC 1452) [here] The UR department has only 24 hours to fax or call the doctor who requested the treatment per Labor Code 4610(g)(3)(a), then UR must send the decision within 2 working days.
Retrospective review: The UR team has 30 days to respond for treatment requests that was not received in a timely manner.
REQUEST FOR AUTHORIZATION: Without a Request for Authorization ("RFA"), the insurance company doesn't own the injured worker (IW) medical treatment. Title 8 CCR 9792.6 [UR Definitions] defines RFA as follows:
| CCR 9792.6(o): "Request for authorization" means a written confirmation of an oral request for a specific course of proposed medical treatment pursuant to Labor Code section 4610(h) or a written request for a specific course of proposed medical treatment. An oral request for authorization must be followed by a written confirmation of the request within seventy-two (72) hours. Both the written confirmation of an oral request and the written request must be set forth on the "Doctor's First Report of Occupational Injury or Illness," Form DLSR 5021, section 14006, or on the Primary Treating Physician Progress Reports, DWC Form PR-2, as contained in section 9785.2, or in narrative form containing the same information required in the PR-2 form. If a narrative format is used, the document shall be clearly marked at the top that it is a request for authorization. |
So, don't forget to REQUEST your 24 Chiropractic Visits right up front. The RFA, as delivered in the doctor's DFR or PR-2 starts the UR process... ONCE THEY HAVE RECEIVED THE REPORT.
SERVICE of the Request for Authorization: Facsimile - the docs best friend.
Fax, Fax, Fax! This is the way to do it. For one, it saves postage, but more importantly, it gets that UR-clock started immediately, as long as you get your faxed PR-2 or DFR in to the insurance company before 5:30pm.
Here's the Law on Service: (CCR 9792.9)
CCR 9792.6(t): states the following: ""Written" includes a facsimile as well as communications in paper form."
CCR 9792.9(a)(1): Is the main Regulation that allows a doctor to fax in his Requests for Authorization. Here's the Regulation:
CCR 9792.9(a)(1): For purposes of this section, the written request for authorization shall be deemed to have been received by the claims administrator by facsimile on the date the request was received if the receiving facsimile electronically date stamps the transmission. If there is no electronically stamped date recorded, then the date the request was transmitted. A request for authorization transmitted by facsimile after 5:30PM Pacific Time shall be deemed to have been received by the claims administrator on the following business day as defined in Labor Code section 4600.4 and in section 9 of the Civil Code. The copy of the request for authorization received by a facsimile transmission shall bear a notation of the date, time and place of transmission and the facsimile telephone number to which the request was transmitted or be accompanied by an unsigned copy of the affidavit or certificate of transmission which shall contain the facsimile telephone number to which the request was transmitted. The requesting physician must indicate the need for an expedited review upon submission of the request. |
Also CCR 9785 (d) states: "The primary treating physician shall render opinions on all medical issues necessary to determine the employee's eligibility for compensation in the manner prescribed in subdivisions (e), (f) and (g) of this section. The primary treating physician may transmit reports to the claims administrator by mail or FAX or by any other means satisfactory to the claims administrator, including electronic transmission.
The moment the insurance company receives the doctor's "request for authorization" in the form of a DFR or PR-2, a clock begins to tick. In a nutshell, LC 4610(g)(1) states that if the PR-2 is received by the insurance company within 10 working days or so (5 for the report and 5 for mail) from the date of the doctors examination, then a 14 day time-deadline is invoked, which is termed a "Prospective Review." The 14 day time-dead line assigned to the prospective review has been supported by a recent WCAB en banc decision [Sandhagen Vs. SCIF I (69 CCC 1452 WCAB en banc, 11/16/04)]: This En Banc WCAB decision 'laid down the law' with respect to UR time-dead lines as it enforced LC 4610(g)(1), which gives the UR department a maximum of "14 days" for the processing/denying of a PTP's timely 'request of authorization' or request for treatment. So, get that Doctor's First Report of Occupational Injury or Illness (DFR) in ON TIME [5 working days per 4603.2(a)]. PR-2 reports should also be served to the insurance company within 5 working days of the examination via Facsimile and/or proof of service. [down load a .pdf of Sandhagen Vs. SCIF here]
If the doctor fails to get his PR-2 report in to the insurance in time, a "Retrospective UR Review" is invoked. Now, the UR doctor has a full 30 days to form his opinion. So, GET YOUR PR-2 REPORTS IN ON TIME!
INFORMING THE DOCTOR of a UR DECISION:
On a prospective review, once a UR Decision has been made, LC 4610(g)(3)(a) dictates that the UR team has "2 business days" to inform the doctor of the decision via "telephone or facsimile" and "in writing." [see LC 4610(g)(3)(a)]
IF NOT APPROVED IN FULL:
Per LC 4610(g)(3)(a), if a doctor's request for treatment, supplies, or anything else is "not approved in full," the dispute "shall be resolved in accordance with Section 4062." So, this means if you don't the medical treatment services you want, request a Panel QME to settle the dispute.
The two Main laws: Labor Code §4610 and Title 8 CCR §9792.8
| the opinion failed to comply with Labor Code § 4610(g)(4), which states, “Responses regarding decisions to modify, delay, or deny medical treatment services requested by physicians shall include a clear and concise explanation of the reasons for the employer's decision, a description of the criteria or guidelines used, and the clinical reasons for the decisions regarding medical necessity." |
Labor Code 4610(g)(4) requires UR reports, which are used to "modify, delay, or deny medical treatment services," "shall include" three key elements:
1) The language of the report "shall include a clear and concise explanation of the reason" for the UR doctors opinion.
2) The UR report "shall include.. a description of the criteria or guidelines used" in making the decision.
3) The UR report "shall include.. the clinical reasons for the decisions regarding medical necessity."
If the UR doctor fails to include any the aforementioned criteria, the report may be objected to on that basis alone and a panel QME may be requested.
8 CCR 9792.8 (a) (3) states in pertinent part:
"The relevant portion of the criteria or guidelines used shall be disclosed in written form to the requesting physician, the injured worker, and if the injured worker is represented by counsel, the injured worker's attorney, if used as the basis of a decision to modify, delay, or deny services in a specific case under review. The claims administrator may not charge an injured worker, the injured worker's attorney or the requesting physician for a copy of the relevant portion of the criteria or guidelines used to modify, delay or deny the treatment request."
Prospective UR Review: This type of review, which is governed by 4610(g)(1), is forced upon the UR department when the doctor gets his PR-2, DFR or Request for Authorization into the insurance company within 5 working days from the date of his/her examination. The UR team is only allowed "5 working days" or in "no event more than 14 days" to render their opinion on the doctor's requested treatment or testing. The WCAB en banc decision of Sandhagen Vs. SCIF I (69 CCC 1452 WCAB en banc, 11/16/04) enforces this ruling and commands any QME or AME NOT to consider any tardy UR opinions in their reports. [See LC 4610(g)(1) here]
Retrospective UR Review: This type of review, which is also governed by 4610(g)(1), is forced upon the UR department when the doctor submits a LATE PR-2, DFR, or Request for Authorization, i.e., past 5 working days from the time of the evaluation or assessment. The UR doctors love this one, for it give them 30 days to comment upon your requests. 30 days is a LONG TIME, so get your reports in ON TIME! [See LC 4610(g)(1) here]
Concurrent UR Review: This is for patients who are in the hospital and doesn't concern us Chiropractors.
ACOEM VARIENCE: (When ACOEM DOESN'T APPLY) + THE 24 CHIRO CAP
Labor Code 4604.5 is the code to site and CCR 9792.8 the regulation to cite when you're treating past the 90 day mark and the patient becomes chronic. As we learned from the two WCAB panel decisions - [Hamilton Vs. SCIF 32 CWCR 249 WCAB panel decision (Oct 2004)] and [Los Angeles Times v. WCAB (Herbinger) 7 WCAB Rptr. 10,109; 70 CCC 504 ( April 2005)] ACOEM is silent and non-applicable when it comes to making recommendation on chronic pain. LC 4604.5 tells us that when ACOEM doesn't apply, you may use other
Labor Code 4604.5 (The Cap)
Title: Medical treatment guidelines. (4604.5(d)(2) they have the power) (4604.5(c)) ACOEM IS REBUTTABLE (4604.5(e)) if ACOEM don’t apply.
History: Amended by Stats 2004, CH 34, effective 04/19/04
(a) Upon adoption by the administrative director of a medical treatment utilization schedule pursuant to Section 5307.27, the recommended guidelines [which are the ACOEM Guidelines] set forth in the schedule shall be presumptively correct on the issue of extent and scope of medical treatment. The presumption is reputable and 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. The presumption created is one affecting the burden of proof.
(b) The recommended guidelines set forth in the schedule adopted pursuant to subdivision (a) shall reflect practices that are evidence and scientifically based, nationally recognized, and peer-reviewed. The guidelines shall be designed to assist providers by offering an analytical framework for the evaluation and treatment of injured workers, and shall constitute care in accordance with Section 4600 for all injured workers diagnosed with industrial conditions.
(c) Three months after the publication date of the updated American College of Occupational and Environmental Medicine's Occupational Medicine Practice Guidelines [ACOEM], and continuing until the effective date of a medical treatment utilization schedule, pursuant to Section 5307.27, the recommended guidelines set forth in the American College of Occupational and Environmental Medicine's Occupational Medicine Practice Guidelines shall be presumptively correct on the issue of extent and scope of medical treatment, regardless of date of injury. The presumption is rebuttable and may be controverted by a preponderance of the evidence establishing that a variance from the guidelines is reasonably required to cure and relieve the employee from the effects of his or her injury, in accordance with Section 4600. The presumption created is one affecting the burden of proof.
(d) (1) Notwithstanding (aka: despite anything to the contrary, in spite of) the medical treatment utilization schedule or the guidelines set forth in the American College of Occupational and Environmental Medicine's Occupational Medicine Practice Guidelines, for injuries occurring on and after January 1, 2004, an employee shall be entitled to no more than 24 chiropractic, 24 occupational therapy, and 24 physical therapy visits per industrial injury.
LC 4604.5(d)(2) This subdivision shall not apply when an employer authorizes, in writing, additional visits to a health care practitioner for physical medicine services.
(e) For all injuries not covered by the American College of Occupational and Environmental Medicine's Occupational Medicine Practice Guidelines or official utilization schedule after adoption pursuant to Section 5307.27, authorized treatment shall be in accordance with other evidence based medical treatment guidelines generally recognized by the national medical community and that are scientifically based.
"OTHER EVIDENCE BASED MEDICAL TREATMENT GUIDELINES." Here's more Detail: UR Page Also, see "Spiel" for verbiage on how to uses these guidelines to help support care.
GLENERIN (CANADIAN) GUIDELINES: (High-Lights)
COLORADO MEDICAL TREATMENT GUIDELINES:
MASSACHUSETTS TREATMENT GUIDELINES: 28 chiropractic visits are allowed during the first 3 months of care. For chronic patients 20 chiropractic treatments (manipulation with 2 procedure or modality visits) for a chronic pain patient.
http://www.guidelines.gov/browse/guideline_index.aspx: National Guideline Clearing House.
http://www.asipp.org/Guidelines.htm: ASIPP Guidelines
http://www.wisconsinmedicalsociety.org/physician_resources/guidelines/workcomp_guide_05draft.pdf: Wisconsin Workers' Compensation Treatment Guidelines: (Support Manipulation for Upper Extremities!) 3 months with 5 times per week allowed for the first two weeks.
Philadelphia Panel Evidence-Based Clinical Practice Guidelines - Low Back
| Intervention: Therapeutic Exercises for Chronic LBP (>12 Weeks) Level I (RCT) Grade A for Pain and Function (Clinically Important Benefit), Grade C for Return to Work (No Benefit Demonstrated) Clinical Recommendations Compared With Other Guidelines: The Philadelphia Panel recommends that there is good evidence to include stretching, strengthening, and mobility exercises (grade A for pain and function, grade C for return to work) as interventions for chronic LBP. The BMJ is in agreement with this EBCPG concerning strengthening exercises. The QTF also recommended the prescription of general exercises as an option to increase strength, ROM, and endurance. The BMJ reported that exercise could have adverse effects due to increased stress on the spine. |
http://www.ifomt.org/ifomt/clinical: IFONMT - List of other guidelines
http://www.sst.dk/Applikationer/cemtv/publikationer/docs/Low-back%20pain/LowBackPain.pdf: Danish Institute for Health Technology Assessement (DIHTA) Guidelines:
"Manual treatment [manipulation / mobilization] can be recommended as an initial treatment for acute exacerbations of recurrent or chronic low-back pain and functional limitation." DIHTA Low-Back Pain Guidelines Chapter 4, page 64, http://www.sst.dk/Applikationer/cemtv/publikationer/docs/Low-back%20pain/LowBackPain.pdf |
Download the "Low Back Pain Medical Treatment Guidelines" Here (in Adobe Acrobat .pdf format)
Download the "Neck pain Medical Treatment Guidelines" Here (in Adobe Acrobat .pdf format)
UR NOT FOR OPINING ON PROPER BILLING CODES:
The new CCR 9792.6 puts an end to a UR doctor commenting on proper billing codes: Here's what sub-section (s) states:
| CCR 9792.6(s) "Utilization review process" means utilization management functions that prospectively, retrospectively, or concurrently review and approve, modify, delay, or deny, based in whole or in part on medical necessity to cure or relieve, treatment recommendations by physicians, as defined in Labor Code section 3209.3, prior to, retrospectively, or concurrent with the provision of medical treatment services pursuant to Labor Code section 4600. Utilization review does not include determinations of the work-relatedness of injury or disease, or bill review for the purpose of determining whether the medical services were accurately billed. |
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