This article provides and overview of medical benefits under the 2010 Medical Treatment Guidelines promulgated by the New York Workers’ Compensation Board.
On December 1, 2010, the Medical Treatment Guidelines become the mandatory standard of care for injured workers, regardless of the date of injury or accident. N.Y.C.R.R. 324.2. Medical care providers are required to treat all existing and new workers’ compensation injuries in accordance with the Medical Treatment Guidelines (MTG) which are incorporated by reference into the regulations. The MTG body-part specific guidelines are:
- New York Mid and Low Back Injury Medical Treatment Guidelines, First Edition, June 30, 2010. Link here (Warning: Links to a large PDF file!)
- New York Neck Injury Medical Treatment Guidelines, First Edition, June 30, 2010. Link here (Warning: PDF)
- New York Knee Injury Medical Treatment Guidelines, First Edition, June 30, 2010. Link here (Warning: PDF)
- New York Shoulder Injury Medical Treatment Guidelines, First Edition, June 30, 2010. Link here (Warning: PDF)
Note: all of these Guidelines self-referentially describe themselves as a “First Edition.” In training delivered to attorneys by the WCB on November 3, 2010, Elain Sobol-Berger, JD/MD, the WCB’s Associate Medical Director, stated that the WCB expects to update these Guidelines as necessary.
Medical care provided to injured workers must satisfy a two-prong test:
- (1) Medical care for workers’ compensation injuries to the neck, low back, mid back, shoulder, and knee must be provided in a manner “consistent with the MTG.” This is the standard for doctors and health care providers to follow.
(2) “Consistent with the MTG” means that care is provided within the criteria and based upon a correct application of the MTG. What is “within the criteria” and “a correct application” is left open for the WCB’s WC Judges to interpret.
The Medical Treatment Guidelines include statements of “General Principles” in each MTG’s first section. These are the key principles necessary to apply and interpret the MTGs. There are 23 general principles divided into 6 categories. Of these, the two most important are:
- (1) Medical Care. 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 approaches. 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.
When are Authorizations Required?
All medical consistent with the MTG is pre-authorized and the health care provider is not required to obtain prior authorization. See N.Y.R.R.C. 324.2(d)(1). There are twelve (12) exceptions to this rule which are defined in the regulations and one (1) additional exception defined in the regulations. So, in total there are thirteen official exceptions – 13 specific procedures that a doctor must get pre-authorization to do.
Now, if you pay close attention, you will realize that these “thirteen exceptions” are really 20 exceptions. Check out the WCB’s published list of procedures that require the health care provider to obtain pre-authorization.
- Mid- and Low Back: lumbar fusion, vertebroplasty, kyphoplasty, and spinal cord stimulator;
- Neck and Low Back: artificial disc replacement and spinal cord stimulator;
- Shoulder: anterior acromioplasty;
- Knee: Chrondroplasty, osteochondral autograft, autologous chrondrocyte implantation, meniscal allograft transplantation and knee arthroscopy (total or partial knee replacement); and
- Duplicative surgery/treatment.
If you list all these procedures separately, you see that there are actually 20 different procedures or treatment scenarios listed here – 6 for the low back, 4 for the mid back, 2 for the neck, 6 for the knee, 1 for the shoulder, and all ‘duplicative treatment.’
Add them up: 6 + 4 + 2 + 6 + 1 + 1 = 20!
Providers who want to perform one of these procedures must request pre-authorization from the carrier before performing the procedure. In addition, the MT specifically forbids any “medical treatment that is experimental and not approved by the FDA.” If the MTG do not address a condition, treatment or diagnostic test for one of the covered body parts, then a variance request can be made to determine whether a carrier will be obligated to pay for the treatment or medical care.
Duplicate surgery or treatment is not ‘automatically’ authorized. Referred to by practitioners as the “13th Exception” this exception requires a medical provider to seek prior approval for repeat or revision care – for example, removal of hardware in a failed fusion attempt.
Questions about the new Medical Treatment Guidelines? Contact me.