GETTING MEDICAL TREATMENT IN THE WORKERS’ COMP SYSTEM

Many injured workers report that they have trouble getting medical treatment in the workers’ comp system because of the Board’s “Medical Treatment Guidelines.” Until now, those guidelines have only covered the neck, back, knee, shoulder, carpal tunnel syndrome and chronic pain. However, the Board plans to expand them to include the hip, foot and ankle, elbow, hand, pulmonary treatment, and mental health care for depression and post-traumatic stress disorder. With that in mind, it’s important to understand how the Guidelines work.

The Guidelines “preauthorize” a variety of treatment, which can include diagnostic tests, a course of therapy, and even some types of surgery. Doctors are not required (and should not) submit requests for approval for treatment that is preauthorized – they can go forward and provide that treatment.

However, if the doctor recommends a type of treatment that is not preauthorized, then the Guidelines assume the treatment is not necessary and should be denied. In that case, the doctor is required to ask for a “variance” from the guidelines in order to get the treatment approved. A variance request can be denied for a number of technical reasons, but the most common problem is that the doctor did not provide a thorough explanation of why the proposed treatment is needed and what the doctor expects the patient to gain from it. The more specific information the doctor provides (test results, range of motion measurements, medical journal articles), the more likely it is that a variance will be approved.