TWO - PRONG TEST:
1) Medical treatment provided for work related injuries to the neck, back, shoulders and/or knees must be "consistent with the MTG".
2) "Consistent with the MTG" means that the treatment is provided within the criteria and correct application of the MTG. The determination of whether the treatment being rendered falls within the criteria and correct application of the MTG is left for the WCB Judges to interpret.
Each first section of the MTGs contains statements of "General Principle", which are crucial to ensure correct application and interpretation of the MTGs. In total there are 23 General Principles, which are divided into 6 categories. Here are the two most important general principles:
1) The purpose of medical care is to restore functional ability required to meet daily and work-related activities, to obtain a positive patient response primarily defined as functional gains which can be objectively measured, and to provide effective treatment which includes evaluations and re-evaluations of treatment and which discontinues ineffective treatments.
2) Treatment should emphasize active interventions over passive modalities (i.e., therapeutic exercise instead of manipulation), should include passive intervention as a means to facilitate progress in an active rehabilitation program, and should resort to surgical interventions only when there is correlation of clinical findings, clinical course, imaging and other diagnostic tests.
PRE-AUTHORIZATION FOR TREATMENTS
Under the MTGs all treatment consistent with the criteria and application are deemed pre-authorized. There are 13 exceptions to that rule, or, 13 specific procedures for which a doctor must obtain pre-authorization:
- Back: lumbar fusion, vertebroplasty, kyphoplasty, low-back artificial disc replacement, and spinal cord stimulator
- Neck: Artificial disc replacement and spinal cord stimulator
- Shoulder: anterior acromioplasty
- Knee: Chrondroplasty, osteochondral autograft, autologous chdrondrocyte implantation, meniscal allograft transplantation and knee arthroscopy (total or partial knee replacement) and any duplicative surgery/treatment.
As noted above, any repeat surgery or treatment requires pre-authorization.
These licenses to perform a treatment either not listed or within the exceptions in the MTGs are much like the old "Request for Authorization" formally filed by virtue of a C-4AUTH. There are four circumstances in which variances must be sought:
1) If the Health Care Provider believes that the Claimant would benefit from a treatment not listed in the MTGs;
2) If the Health Care Provider believes that the Claimant would benefit from a treatment that is within the MTGs but not recommended by the MTGs;
3) If the Health Care Provider believes that the Claimant would benefit from treatment found in the MTGs but not specified at this point in the course of the Claimant's treatment; or
4) If the Health Care Provider believes that the Claimant would benefit from treatment that is within the MTGs but exceeds the maximum number or frequency limit for that particular treatment.
HOW TO REQUEST VARIANCES
Variances must be requested by filing the form MG-2 (accessible via this link http://www.wcb.state.ny.us/content/main/forms/MG2.pdf). The entire form must be completed and signed by the Health Care Provider and submitted both to the Carrier and the Workers' Compensation Board (can be faxed to the WCB at 1-877-533-0337). If the Health Care Provider is requesting more than one treatment, he/she should use the form MG-2.1 for each additional treatment being requested (accessible via this link http://www.wcb.state.ny.us/content/main/forms/MG2_1.pdf). Both forms must be transmitted at the same time to the WCB. The Health Care Provider must provide:
- the basis for the opinion that the treatment or test being requested is appropriate and medically necessary;
- a statement that the Claimant agrees to the proposed treatment/test;
- any signs or symptoms which failed to improve with treatment provided in accordance with the guidelines; or
- the objective improvements made by a particular treatment and the expected improvements with more of the same treatment.
Treatments that are specifically eliminated by the MTGs, such as discography) will not be approved.
OPTIONAL PRE-APPROVAL REQUEST
Health Care Providers who wish to make sure that the treatment being rendered is in accordance with the MTGs can file an optional request for approval by submitting a form MG-1 (accessible via this link http://www.wcb.state.ny.us/content/main/forms/MG1.pdf). The form should be completely filled out and submitted to both the Carrirer and the WCB for review. If more than one treatment is being contemplated for which optional prior approval is being sought, the Health Care Provider should file form MG-1.1 (accessible via this link http://www.wcb.state.ny.us/content/main/forms/MG1_1.pdf) for prior each additional treatment.