a-z indexroundtableArticles & Editorialsmarketplacemeet the publisherscontactsearch
home
  A-Z Index
A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z

MEDICAL TREATMENT DISPUTES

SB 863 Under the California Constitution, there must be “full provision for such medical, surgical, hospital and other remedial treatment as is requisite to cure and relieve from the effects of such injury.” Decades of litigation and legislation have defined and limited this clause. Note that “cure and relieve” in the Constitution became “cure or relieve” in Labor Code §4600. Thus, palliative care is allowed.

Also allowed is treatment required by industrial aggravation of a non-industrial condition or when a non-industrial condition must be treated before treatment to “cure or relieve” the industrial condition can be undertaken (e.g., weight loss treatment needed before a knee replacement). See Braewood Convalescent Hosp. v. WCAB.

Expenses incidental to receiving treatment (e.g., travel) are covered. See Hutchinson v. WCAB.

Medical treatment payable by the employer for a work injury is controlled by Treatment Guidelines, and statutes limiting certain types of treatment (chiropractic, physical and occupational therapy: see Labor Code §4604.5an employee is entitled to no more than 24 chiropractic, 24 occupational therapy and 24 physical therapy visits per industrial injury. If there is surgery, the statutory limitations do not apply and the treatment guidelines in 8 CCR 9792.24.3 are used instead). Treatment is also controlled by having the employer select the treater in most cases: see below.

Other forms of treatment are allowed, with limitations: see
Labor Code §§3209.7, 3209.8, 3209.

In the great majority of cases, the choice of physician is controlled by Medical Provider Networks. See, too, Primary Treating Physician and Change of Primary Treating Physician. In a serious case, the employee is entitled to a second opinion.

Fees for medical treatment are controlled by the Official Medical Fee Schedule (OMFS). See Labor Code §5307.1. SB 863 made major changes to the OMFS. It also made major changes to disputes over payment for medical treatment: see Independent Bill Review

Requests for treatment are controlled by regulations. Disputes over treatment are controlled by utilization review and independent medical review. Note that SB 863 revised Labor Code §4062(a) to delete the special provisions for spinal surgery recommendations. 

Medical treatment cannot be apportioned (Granado v. WCAB).

See Medical Treatment, Independent Medical Review
Label Item Links Comments
Labor Code Labor Code §4600: treatment “reasonably required to cure or relieve the injured worker from the effects of his or her injury shall be provided by the employer”

Labor Code §3209.7: Treatment may include “any other form of therapy, treatment, or healing practice agreed upon voluntarily in writing, between the employee and his employer.”
LC §4600



Labor Code §3209.7
 
Regulations/Rules 

Determination of Medical Treatment Disputes: 8 CCR §§10451.2

A multitude of DWC regulations govern medical treatment: see Links

Application of the Official Medical Fee Schedule (Treatment)

8 CCR §10451.2

 

MPN Regs

OMFS

 
Requests for Authorization 8 CCR §9785.5
Cases  Braewood Convalescent Hosp. v. WCAB

Hutchinson v. WCAB :
liberal construction

Granado v. WCAB: No apportionment for cost of treatment
Braewood

Hutchinson v. WCAB.

Granado v. WCAB
 
Forms Request for Authorization  RFA   
Websites DWC Medical Unit DWC Medical Unit  
Practice Tips  There are hoops to jump through before filing for penalties, undertaking IMR, etc. Make sure the PTP's report is substantial evidence: does it identify with any clarity why the requested treatment is required or why it is needed to cure or relieve applicant from the effects of his or her injuries? If not, seek a narrative report (see Swift on How to get a CMLE).    
Articles
The AME/PQME Quagmire on Determining Medical Necessity Post SB 863 by Robert G. Rassp, Esq.
Rassp on Determining Medical Necessity  
Magazine Articles
 
Roundtable    
Miscellaneous      

A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z