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Getting to YES with UR & IMR

By Steven D. Feinberg, M.D.

Steven D. Feinberg, M.D., is a board certified specialist in Physical Medicine & Rehabilitation, Pain Medicine, and Electrodiagnostic Medicine, and has authored many articles on pain treatment. In this article he discusses how to write treatment requests that meet evidence-based guidelines.

     

This document is meant to help physicians and others better serve injured workers through understanding how to provide requests for treatment that meets evidence-based medicine guidelines leading to authorization for medical care. While not foolproof, if physicians follow the directions below they can avoid most authorization denials through UR and IMR. This does involve a little extra work at the front end, but it saves having to deal with and respond to denials of care which only clog up the physician’s office and take up time while leaving the injured worker patient without needed medical care.

 
If physicians follow the directions below they can avoid most authorization denials
 
The Rules

• Doctors in California's workers' compensation system are required to provide evidence-based medical treatment.
• All treatment in California must be consistent with the MTUS (LC §5307.27) which is presumptively correct as a matter of law (LC §4604.5(a)).
Requests that are inconsistent with the MTUS = Denial / Non-Certified.
• The physician can go down the right hierarchy when the MTUS does not address the treatment request, does not adequately consider unique treatment requests, or where there is stronger and more up-to-date scientific evidence to support the request.
Text of Medical Treatment Utilization Schedule Regulations (MTUS)
• The physician must choose treatments scientifically proven to cure or relieve work-related injuries and illnesses.
§9792.25. Presumption of Correctness, Burden of Proof and Strength of Evidence
(a) The MTUS is presumptively correct on the issue of extent and scope of medical treatment and diagnostic services addressed in the MTUS for the duration of the medical condition.
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.
(b) For all conditions or injuries not addressed by the MTUS, authorized treatment and diagnostic services shall be in accordance with other scientifically and evidence-based medical treatment guidelines that are nationally recognized by the medical community.
(c)(1) For conditions or injuries not addressed or at variance by either subdivisions (a) or (b) above or where a recommended medical treatment or diagnostic service covered under subdivision (b) is at variance with another treatment guideline also covered under subdivision (b), ACOEM's strength of evidence rating methodology is used.
000Evidence-base: Insufficient – Limited – Moderate - Strong
Labor Code §4610.5(c)(2) as revised by SB 863:
(2) “Medically necessary” and “medical necessity” mean medical treatment that is reasonably required to cure or relieve the injured employee of the effects of his or her injury and based on the following standards, which shall be applied in the order listed, allowing reliance on a lower ranked standard only if every higher ranked standard is inapplicable to the employee's medical condition:
(A) The guidelines adopted by the administrative director pursuant to Section 5307.27.
(B) Peer-reviewed scientific and medical evidence regarding the effectiveness of the disputed service.
000See Pubmed
(C) Nationally recognized professional standards.
000ACOEM, ODG, Others (see http://www.guideline.gov/)
(D) Expert opinion.
(E) Generally accepted standards of medical practice.
(F) Treatments that are likely to provide a benefit to a patient for conditions for which other treatments are not clinically efficacious.


Treating doctors must provide evidence-based treatment
 

Overview of MTUS

For many body parts (see below), the MTUS uses the ACOEM 2004 2nd Edition although all Chapters have been updated. If the 2004 Chapter does not provide the most accurate and up to date scientific evidence based medicine supported request for treatment, consider #2 - #7 hierarchy above.

† The updated ACOEM Chapters can be purchased at https://webportal.acoem.org/Purchase/CatalogSearchResults.aspx?Option=2&Topic=15 for $5.95 a Chapter. They can also be found at http://www.guideline.gov/search/search.aspx?term=acoem.
† You can purchase use of the Official Disability Guidelines (ODG) $350/year. The 2011 version can also found at http://www.guideline.gov/search/search.aspx?term=work+loss+data.
† Many Guidelines including ACOEM and prior ODG versions can be obtained free at http://www.guideline.gov/

CA DWC Medical Treatment Utilization Schedule MTUS)
• Neck and Upper Back Complaints
ACOEM 8 (2004, 2nd Edition)
Acupuncture Medical Treatment Guidelines
Postsurgical treatment Guidelines
• Shoulder Complaints
ACOEM 9 (2004, 2nd Edition)
Chronic Pain Medical Treatment Guidelines
Postsurgical treatment Guidelines
• Elbow Disorders
ACOEM 10 (Revised 2007)
Acupuncture Medical Treatment Guidelines
Chronic Pain Medical Treatment Guidelines
Postsurgical treatment Guidelines
• Forearm, Wrist & Hand Complaints
ACOEM 11 (2004, 2nd Edition)
Acupuncture Medical Treatment Guidelines
Chronic Pain Medical Treatment Guidelines
Postsurgical treatment Guidelines
• Low Back Complaints
ACOEM 12 (2004, 2nd Edition)
Chronic Pain Medical Treatment Guidelines
Postsurgical treatment Guidelines
• Knee Complaints
ACOEM 13 (2004, 2nd Edition)
Acupuncture Medical Treatment Guidelines
Chronic Pain Medical Treatment Guidelines
Postsurgical treatment Guidelines
• Ankle and Foot Complaints
ACOEM 14 (2004, 2nd Edition)
Acupuncture Medical Treatment Guidelines
Chronic Pain Medical Treatment Guidelines Postsurgical treatment Guidelines
• Stress Related Conditions
ACOEM Chapter 15 (2004, 2nd Edition)
• Eye Conditions
ACOEM Chapter 16 (2004, 2nd Edition)
• Chronic Pain Complaints
Chronic Pain Medical Treatment Guidelines
• Acupuncture
Acupuncture Medical Treatment Guidelines
• Postsurgical Therapy / Treatment
Postsurgical Treatment Guidelines (https://www.dir.ca.gov/dwc/MTUS/MTUS_RegulationsGuidelines.html#15)


More on the MTUS
 

Report Writing

• Physician needs to provide a clear, legible and concise history and physical examination followed by diagnoses and then recommendations for evidence-based medicine (EBM) medical care.
• Timely submitted reports will help expedite proposed treatment and avoid unnecessary delays unrelated to the UR process.
• Avoid boilerplate paragraphs especially with an electronic medical record (EMR).
• State how the medical treatment is supported by the MTUS or how your request is supported by another medical standard and why every standard ranked higher in the hierarchy (see hierarchy above) is inapplicable to the injured worker’s medical condition.
• Walk the UR or IMR Reviewer through the treatment course and document how the treatment request meets the MTUS or EBM standards.
• The medical reporting must contain documentation that the injured worker is educated about and understands the diagnoses and additionally should note specific goals to be achieved and documented with treatment which include:
Less discomfort
Improved activities of daily living function
000 Improved sleep
000 Increased ADLs such as cleaning the house, mowing the lawn, etc.
Staying or returning to work


What is needed in the report?
 

Post-UR & IMR Denial

• If there has already been a UR denial, discuss how the Utilization Reviewer erred in the analysis.
• What documentation or evidence or report did the Utilization Reviewer miss or not consider.
• Learn from your UR mistakes - If the UR physician has pointed out legitimate errors in your reporting, correct the deficiency prior to IMR.

To read the rest of this article, click here.


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Steven D. Feinberg, M.D.

Dr. Feinberg is a physiatrist and pain medicine specialist practicing in Palo Alto. He is an Adjunct Clinical Professor and teaches at the Stanford University Pain Service. Dr. Feinberg is a past president (1996) of the American Academy of Pain Medicine (AAPM). He served as a California Society of Medicine & Surgery (CSIMS) Year 2001 President. He serves on the Board of Directors of the American Chronic Pain Association and is lead author of the 2012 ACPA Resource Guide to Pain Medication & Treatment. He is the Medical Director of Cedaron AMA Guides Software.

Dr. Feinberg served on the ACOEM Chronic Pain Guidelines Panel Chapter Update and also as an Associate Editor and he also serves as a consultant to the Official Disability Guidelines (ODG). He readily admits to a bias towards a functional restoration treatment approach.

American Board of Pain Medicine
American Board of Electrodiagnostic Medicine
American Board of Physical Medicine & Rehabilitation
Qualified Medical Evaluator

Feinberg Medical Group
825 El Camino Real Palo Alto, CA 94301
Tel 650-223-6400
Fax 650-223-6408
stevenfeinberg@hotmail.com
Feinberg Medical Group (FMG)


 


 
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