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Answers to frequently asked questions about medical treatment utilization schedule (MTUS)

new image The FAQs below apply to claims filed on or before Jan. 1, 2013. Updated information based upon the implementation of SB 863 and its changes to California’s workers’ compensation system will be available soon.

Topics covered in this FAQ include:

The basics
General applicability
Chronic pain medical treatment
Postsurgical therapy

About the basics:

Q. Where can I find the medical treatment guidelines?

A. The medical treatment guidelines are contained in the medical treatment utilization schedule (MTUS) regulations which can be found in the California Code of Regulations, Title 8, section 9792.20 et seq. You may obtain an electronic copy of the MTUS regulations from the Division of Workers’ Compensation  (DWC) Web site at http://www.dwc.ca.gov.

About general applicability:

Q. When new versions of the same guidelines incorporated into the MTUS become available do the revised versions of the guidelines automatically apply to provide medical treatment to the injured employee?

A. No. The applicable guidelines to provide medical treatment to the injured employee are the guidelines contained in the MTUS on the last effective date of the MTUS regulations. New revised versions of guidelines that become available apply only when they are incorporated into the MTUS through formal rulemaking. However, if the new revised versions of the guidelines contain different recommendations based on new evidence compared to the already incorporated guidelines, the new scientific evidence may be considered if the new guidelines are at variance with the version of the guideline found in the MTUS. 

About chronic pain medical treatment:

Q. Which MTUS guidelines apply when the injured employee is diagnosed with chronic pain and the treatment for the condition is not addressed in the chronic pain medical treatment guidelines but is addressed in the clinical topics guideline for the specific body part?

A. The clinical topics guidelines for the specific body part apply to the treatment for the chronic pain condition. (§9792.24.2(c).)

Q Which MTUS guidelines apply when the injured employee is diagnosed with chronic pain and the treatment for the condition is addressed in both the chronic pain medical treatment guidelines and the clinical topics guideline for the specific body part?

A. The chronic pain medical treatment guidelines apply to the treatment for the chronic pain condition. (§9792.24.2(d).)

About postsurgical therapy

Q. When do the postsurgical treatment guidelines apply?

A. The postsurgical treatment guidelines apply when surgery has been performed and postsurgical physical medicine is medically necessary regardless of date of injury. The postsurgical treatment guidelines apply as an exception to the 24-visit statutory cap for chiropractic, occupational and physical therapy.

Q. What is the postsurgical physical medicine treatment period?

A. It is the time interval that physical medicine treatment can be provided as an exception to the 24-visit cap. It begins on the date of surgery and ends within the time interval for the specific surgery as defined in the regulations. During the postsurgical physical medicine treatment period postsurgical treatment and rehabilitation services may be provided and these visits do not count against the statutory cap. After the postsurgical physical medicine treatment period ends, additional therapy visits will come from any visits remaining under the 24-visit cap. If the surgical procedure is not addressed in the postsurgical treatment guidelines, the postsurgical physical medicine period is six (6) months. (§9792.24.3(a)(3).)

Q. Does the postsurgical physical medicine treatment period include the 24 visits for chiropractic, occupational and physical therapy pursuant to Labor Code §4604.5(d)(1)?

A. No. Physical medicine visits during the postsurgical physical medicine period represent an exception to the 24-visit statutory cap for chiropractic, occupational and physical therapy. The 24-visit statutory cap becomes effective once the postsurgical physical medicine period ends. (§9792.24.3(b)(1).)

Q. Who can determine whether postsurgical physical medicine is appropriate?

A. The surgeon who performed the surgery and his surgical team (e.g., a nurse practitioner working with the surgeon or a physician designated by the surgeon) can make a determination of medical necessity and prescribe postsurgical physical medicine pursuant to the postsurgical treatment guidelines. (§9792.24.3(c)(1).)

Q. Is the request for approval of postsurgical physical medicine under the postsurgical treatment guidelines subject to utilization review?

A. Yes. A request for authorization of postsurgical physical medicine is subject to utilization review pursuant to the utilization review regulations (§9792.6 et seq.) The utilization review organization is required to review the request for authorization applying its standards pursuant to the MTUS, and specifically pursuant to the postsurgical treatment guidelines. (§9792.7(a)(3).)

November 2012