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Chapter 4.5. Division of Workers' Compensation
Subchapter 1. Administrative Director--Administrative Rules
Article 5.5.2. Medical treatment utilization schedule
(a) The Administrative Director adopts the Medical Treatment Utilization Schedule (MTUS) consisting of section 9792.20 through section 9792.26.
(b) The MTUS is based on the principals of Evidenced-Based Medicine (EBM). EBM is a systematic approach to making clinical decisions which allows the integration of the best available evidence with clinical expertise and patient values. EBM is a method of improving the quality of care by encouraging practices that work and discouraging those that are ineffective or harmful. EBM asserts that intuition, unsystematic clinical experience, and pathophysiologic rationale are insufficient grounds for making clinical decisions. Instead, EBM requires the evaluation of medical evidence by applying an explicit systematic methodology to determine the quality and strength of evidence used to support the recommendations for a medical condition or injury. The best available evidence is then used to guide clinical decision making.
(c) The recommended guidelines set forth in the MTUS are presumptively correct on the issue of extent and scope of medical treatment. The MTUS constitutes the standard for the provision of medical care in accordance with Labor Code section 4600 for all injured workers diagnosed with industrial conditions because it provides a framework for the most effective treatment of work-related illness or injury to achieve functional improvement, return-to-work, and disability prevention. The MTUS shall be the primary source of guidance for treating physicians and physician reviewers for the evaluation and treatment of injured workers.
(d) Treatment shall not be denied on the sole basis that the condition or injury is not addressed by the MTUS. There are two limited situations that may warrant treatment based on recommendations found outside of the MTUS.
(1) First, if a medical condition or injury is not addressed by the MTUS, medical care shall be in accordance with other medical treatment guidelines or peer-reviewed studies found by applying the Medical Evidence Search Sequence set forth in section 9792.21.1.
(2) Second, if the MTUS' presumption of correctness is successfully challenged. The recommended guidelines set forth in the MTUS are presumptively correct on the issue of extent and scope of medical treatment. The presumption is rebuttable and may be controverted by a preponderance of scientific medical evidence establishing that a variance from the schedule 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. Therefore, the treating physician who seeks treatment outside of the MTUS bears the burden of rebutting the MTUS' presumption of correctness by a preponderance of scientific medical evidence.
1. New section filed 6-15-2007; operative 6-15-2007 pursuant to Government Code section 11343.4 (Register 2007, No. 24).
2. Amendment of subsection (a), renumbering of former subsection (a)(1) to section 9792.22, subsection (a), renumbering of former subsections (a)(2)-(a)(2)(E) to new section 9792.24.1 and amendment of subsections (b) and (c) filed 6-18-2009; operative 7-18-2009 (Register 2009, No. 25).
3. Editorial correction of operative date in History 2 (Register 2009, No. 30).
4. Amendment of section and Note filed 4-20-2015; operative 4-20-2015 pursuant to Government Code section 11343.4(b)(3) (Register 2015, No. 17).