How MTUS relates to workers compensation claims

The Language of the Medical Treatment Utilization Schedule (MTUS) and Workers’ Compensation Approval of Medical Treatment: What You Need to Know

California Workers’ Compensation Medical Treatment is confusing to Injured Workers. Injured Workers frequently have problems getting medical care. Many times, the treatment requests from their Treating Physicians are denied by the Insurance Company via a Utilization Review process.

This article will discuss and explain some of the terms used with respect to the Medical Treatment Utilization Schedule and what they mean to Injured Workers. These definitions are from 8 CCR § 9792.20.

What is a “Medical Treatment Utilization Schedule?” Why Is It Important?

A Medical Treatment Utilization Schedule addresses what should be considered as appropriate treatment with respect to the appropriate type of treatment, the frequency of treatment, the duration of the treatment, the intensity of the treatment.

Per the California Labor Code, for industrial injuries, the Medical Treatment Utilization Schedule “shall incorporate the evidence-based, peer-reviewed, nationally recognized standards of care recommended by the commission pursuant to Section 77.5, and that shall address, at a minimum, the frequency, duration, intensity, and appropriateness of all treatment procedures and modalities commonly performed in workers’ compensation cases.”

This is important to the Injured Worker in that they understand that their treatment is not solely guaranteed by the fact that their Treating Physician has made a request for the services. These recommendations are subject to this Schedule.

What is “ACOEM?” Why Is It Important?

“ACOEM” means “the American College of Occupational and Environmental Medicine’s Occupational Medicine Practice Guidelines published by the Reed Group containing evidenced-based medical treatment guidelines for conditions commonly associated with the workplace. ACOEM guidelines may be obtained from the Reed Group. Regulation § 9792.20(a.)”

This is important to the Injured Worker in that these Guidelines are incorporated into the MTUS.

What Is “Chronic Pain?” Why Is It Important?

“Chronic Pain” means pain lasting three or more months from the initial onset of pain.

This is important to the Injured Worker in that a designation of “chronic pain” may have an impact as to what treatments can be recommended or approved.

What is the “Claims Administrator?” Why is it Important?

“Claims administrator” is a self-administered workers’ compensation insurer, a self-administered self-insured employer, a self-administered legally uninsured employer, a self-administered joint powers authority, a third-party claims administrator, or the California Insurance Guarantee Association.”

This is important to the Injured Worker in that the Claims Administrator is the one who is responsible for doing the utilization review of medical treatment requests.

What Is “Evidence-Based Medicine?” Why is It Important?

“Evidence-Based Medicine (EBM)” means a “systematic approach to making clinical decisions which allows the integration of the best available research evidence with clinical expertise and patient values.”

This is important to the Injured Worker in that medical treatment must be based upon scientific evidence such as studies. Therefore, requests unique forms of treatment for which there no research supporting a unique form of treatment, it is unlikely it will be approved.

What Is “Functional Improvement?” Why is it Important?

“Functional Improvement” means “either a clinically significant improvement in activities of daily living or a reduction in work restrictions as measured during the history and physical exam, performed and documented as part of the medical evaluation and treatment; and a reduction in the dependency on continued medical treatment.”

This is important for Injured Workers in that the determinations to approve certain treatments will be looking to see whether there has been functional improvement as a result of the treatment. If there has been no functional improvement, this may diminish the likelihood that further similar treatment will be approved. If there has been functional improvement, this may increase the likelihood that similar treatment will be approved.

What is “Medical Treatment?” Why is it Important?

“Medical Treatment” is “care which is reasonably required to cure or relieve the employee from the effects of the industrial injury consistent with the requirements of sections 9792.20-9792.26.””

This is important for Injured Workers in that medical treatment is not simply medical treatment. Medical treatment must cure or relieve from the effects of the industrial injury AND be consistent with the Guidelines. Therefore, there are essentially two requirements for treatment to be approved. First, the cure or relief from requirement and second, that the treatment complies with the guidelines.

What are “Medical Treatment Guidelines?” Why are They Important?

“Medical Treatment Guidelines” means the most current version of written recommendations which are systematically developed by a multidisciplinary process through a comprehensive literature search to assist in decision-making about the appropriate medical treatment for specific clinical circumstances reviewed and updated within the last five years.

This is important to Injured Workers in that guidelines are not necessarily written in stone. They are changing and evolving. Treatments recommended in the past, i.e. such as opioid medications, are now not in favor and are discouraged, and newer treatments and therapies, i.e. plasma-rich platelet injections, may become accepted as a form of treatment.

What is “Nationally Recognized”? Why is It Important?

“Nationally Recognized” means “published in a peer-reviewed medical journal; or developed, endorsed and disseminated by a national organization with affiliates based in two or more U.S. states and is the most current version.”

What are the “Official Disability Guidelines?” Why Are They Important?

“ODG” means the “Official Disability Guidelines published by the Work Loss Data Institute containing evidenced-based medical treatment guidelines for conditions commonly associated with the workplace. ODG guidelines may be obtained from the Work Loss Data Institute, 169 Saxony, #101, Encinitas, California 92024 (https://www.mcg.com/odg/).”

This is important to the Injured Worker in that the ODG may offer some explanation or insight as to why their treatment is being approved or being denied.

What Does “Peer Reviewed” Mean? Why Is It Important?

“Peer Reviewed” means that “a study’s content, methodology and results have been evaluated and approved prior to publication by an editorial board of qualified experts.”

This is important to the Injured Worker in that Peer Reviewed studies are ones that are of a better quality and should recommend the most effective forms of treatment.

What is “Scientifically-Based”? Why is It important?

“Scientifically-Based” means “based on scientific literature, wherein the body of literature is identified through performance of a literature search, the identified literature is evaluated, and then used as the basis to support a recommendation.”

This is important to Injured Workers in that they should not have the expectation of getting treatment for which there is no scientific basis. Many times, Injured Workers hear of treatments that may be interesting to help them. These treatments, however, may not get approved without scientific backing. Likewise, if there is scientific backing, there is hope that a treatment may, in fact, be approved.

What Is “Strength of Evidence?” Why is it Important?

“Strength of Evidence” establishes the relative weight that shall be given to scientifically based evidence.”

This is important for Injured Workers in that, just because there may be a study that supports a form of medical treatment, that it will be analyzed in terms of its strength against other studies and opinions. So, one article recommending a treatment may not be enough.

What If I Need Legal Advice?

If you would like a “free” consultation concerning any workers’ compensation case, please contact the Law Offices of Edward J. Singer, a Professional Law Corporation. They have been helping people in Central and Southern California deal with their worker’s compensation cases for 28 years. for more information.

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