Doctors in California’s workers’ compensation system are required to provide evidence-based medical treatment. That means they must choose treatments scientifically proven to cure or relieve work-related injuries and illnesses. When evidence based medicine became the standard in California Worker’s Compensation it started with the American College of Occupational and Environmental Medicine (ACOEM) Guideline. The California use of the ACOEM Guideline evolved by the addition of missing components to what is now known as the Medical Treatment Utilization Schedule (MTUS).Today, approved treatments are laid out in the Medical Treatment Utilization Schedule (MTUS), which contains a set of guidelines that provide details on which treatments are effective for certain injuries, as well as how often the treatment should be given, the extent of the treatment, and for how long, among other things. The MTUS is based in part on the ACOEM Guidelines.
The improvements to the MTUS are made over time by the DWC rule making process. The Office of Administrative Law has just approved the Division of Workers’ Compensation’s (DWC) final version of the Medical Treatment Utilization Schedule (MTUS) amended regulations. The MTUS regulations went into effect April 20, 2015.
“These regulations will clarify the process to be used to evaluate medical evidence and are required to be applied when there are competing recommendations and a dispute about which recommendation shall guide the injured worker’s medical care,” said Dr. Rupali Das, DWC Executive Medical Director. “The clarity will allow treating physicians, reviewing physicians and claims administrators to make better informed decisions and should reduce disputes over medical treatment.”
The new MTUS regulations include:
1) Clarification of the role of the MTUS as the primary source of guidance for treating physicians and physician reviewers for the evaluation and treatment of work-related illness or injury, and that the MTUS constitutes the standard of care for the provision of medical care in accordance with Labor Code section 4600.
2) A description of the two limited situations that may warrant treatment based on recommendations found outside of the MTUS: (1) if the medical condition or injury is not addressed by the MTUS, or (2) if the MTUS’ presumption of correctness is successfully rebutted.
3) Guidance in how to conduct a search for medical evidence in order for treating physicians and reviewing physicians to consistently and efficiently navigate the vast array of medical literature.
4) Requirements for treating physicians and reviewing physicians to properly complete and document Requests for Authorizations, Utilization Review Decisions and Independent Medical Review Decisions as it relates to the medical evidence that the physician believes guides the reasonableness and necessity of the requested treatment.
5) The methodology that shall be applied by reviewing physicians to evaluate the quality and strength of evidence used to support competing recommendations. 6) An amendment to the composition of the Medical Evidence Evaluation and Advisory Committee to include two additional members, one from the pharmacology field and one from the nursing field.
The final regulations are posted on the DWC website.