What is the "burden of proof" for a provider seeking a variance?

There are three basic types of variance requests. The provider must present documentation showing that the proposed treatment, which may be 1. An extension beyond the maximum duration or frequency recommended in the MTG, 2. Not recommended in the MTGs, or 3. Not addressed in the MTG is medically necessary and likely to be effective for the patient. The documentation required varies depending upon the type of variance (treatment) the provider is seeking. To satisfy the burden of proof, the provider must meet the documentation requirements for the type of variance requested. All variance requests must include:
1. A medical opinion stating why the proposed care is appropriate and medically necessary for the patient
2. Certification by the requesting provider that the patient agrees to the proposed care, and
3. An explanation why alternatives under the MTGs are not appropriate or sufficient

Additionally, requests to extend treatment beyond recommended maximum duration/frequency must include:

4. Objective evidence that the requested treatment has produced functional improvement,
5. Further improvement is reasonably expected with additional treatment. Documentation should include explanation as to why treatment has not produced maximum effect and
6. Proposed plan for additional treatment with the treatment duration and frequency, and functional goals.

Finally, for treatment or testing that is not recommended or not addressed, the following must be documented:

1. A description of any signs or symptoms which have failed to improve with previous treatments provided according to MTG recommendations
2. Proposed treatment plan and an explanation of why proposed treatment or testing is necessary at this time, including specific functional goals, if applicable.
3. Medical evidence in support of efficacy of the proposed treatment or testing – may include relevant medical literature published in recognized peer reviewed journals.