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New York State
Workers' Compensation Board
OFFICE OF THE CHAIR
20 Park Street   Albany, New York 12207
Governor Andrew M. Cuomo


MDO-2011 #2

Medical Director's Office Bulletin

Clarification Regarding Appropriate Use And Completion Of
New Workers' Compensation Forms

Date: July 14, 2011

To: All Workers' Compensation Medical Providers

This bulletin emphasizes and clarifies the importance of the appropriate use and completion of the new Workers' Compensation forms introduced as a result of the implementation of the Medical Treatment Guidelines (MTG).

The Workers' Compensation Board introduced the MG-1 (and MG-1.1) forms for optional prior approval requests and the MG-2 (and MG-2.1) forms for variance requests. Additionally, the C-4AUTH form has been revised with added sections for use under two circumstances: (1) to request pre-authorization for the 13 treatments that are covered by the MTG but require prior authorization, and (2) to request treatment that costs $1000 or more and is not covered by the MTG.

Variance (Form MG-2)

The variance process is designed for treating providers to request approval of treatment that is different from the MTG recommendations or extends beyond the guidelines' frequency or duration recommendations. The variance process should not be used to request treatment that is consistent with the guidelines. Variance requests for pre-approved treatment that is consistent with the guidelines will be denied.

Appropriate Completion of Form MG-2

The submission of an incorrect or incomplete form may result in the Board's rejection of the form and an unnecessary delay in care. A complete and accurate MG-2 form must include:

  • Claimant's name;
  • Doctor's signature or stamp, WCB Authorization Number and fax number;
  • Date and method of transmission (if a fax number is provided, the certification box checked for method of transmission must be "by fax," not "by mail" in section "C");
  • Guideline Reference (for clarification see details below);
  • Treatment for which approval is requested;
  • Statement of medical necessity (either a written description or documentation attached to the MG-2 form or reference a date of service in the WCB file where the supporting medical documentation can be found);
  • And completion of one of two boxes certifying that the form was faxed or emailed to carrier/employer/self-insured employer/special fund or box checked that provider does not have fax or e-mail capability and the date that copies were mailed.

Medical Treatment Guideline Reference

The variance form(s) (MG-2 and MG-2.1) must include the medical treatment guideline reference, indicating the body part (B, N, S, K) in the first box and followed by at least two subset codes in the remaining boxes, depending upon the body part (e.g., a variance request for Back Massage (Manual or Mechanical) has four possible MTG references, each with four subset codes: [B]-[D][10][c][i] or [B]-[D][10][c][ii] or [B]-[D][10][c][iii] or [B]-[D][10][c][iv], while Testing Procedures for a Knee Meniscus Injury has one MTG reference code with three subset codes[K]-[D][6][d][ ]).

If the variance is requested for a body part covered in the MTG, but the procedure or treatment is not addressed in the guidelines, the Medical Provider should use the appropriate MTG body part letter only in the first box and the word NONE in the subsequent boxes (e.g., [B]-[N][O][N][E]).

Supporting Medical Documentation

The treating provider must provide documentation to support a variance request. The burden of proof that a variance is appropriate and medically necessary rests with the treating medical provider requesting the variance. The regulations clearly define the criteria and required documentation:

  1. For all variances:
    1. medical opinion, including the basis for the opinion, that the proposed medical care that varies from the MTG is appropriate and medically necessary, and
    2. a statement that the claimant agrees to the proposed medical care, and
    3. an explanation of why alternatives under the MTG are not appropriate or sufficient, and
  2. For appropriate claims:
    1. a description of any signs or symptoms which have failed to improve with previous treatments provided in accordance with the MTG; or
    2. if the variance involves frequency or duration of a particular treatment, a description of the functional objective outcomes that, as of the date of the variance request, have continued to demonstrate objective improvement from that treatment and are reasonably expected to further improve with additional treatment.

Treating medical providers may submit citations or copies of relevant literature published in peer-reviewed medical journals in support of a variance request.

Variance requests that do not include a specific guideline reference, a statement of medical necessity, and supporting medical documentation cannot be evaluated and will not be processed by the Board. Medical documentation should conform to the general principles outlined in the initial portion of each one of the medical guidelines, especially in relation to defining positive patient response (A.3) and re-evaluation of treatment (A.4).

Optional Prior Approval (Form MG-1)

The optional prior approval process is designed to provide a formal means of ensuring that the carrier agrees that proposed treatment is consistent with the MTG. It is optional for the treating provider and is only available if the insurance carrier has decided to participate in the process. A list of NON-participating carriers is available on the Board's website.

If the carrier is participating, the optional prior approval form(s) (MG-1 and MG-1.1) must include the medical treatment guideline reference [   ]-[   ][   ][   ][   ], indicating the body part in the first box and the applicable section of the WCB MTG in the remaining boxes (e.g., for an optional prior approval request for Strengthening and Stabilization Exercises in the Back, the code reference would read [B]-[D][9][c][i]).

If the carrier is not participating in optional prior approval, the treating provider should NOT submit an MG-1 form. The provider may still contact the carrier informally to discuss applicability of the guidelines if the provider has any concerns about the proposed treatment plan.

C-4 Authorization (Form C-4AUTH)

The MTG pre-approve the vast majority of recommended treatment that is consistent with the guidelines. There are twelve recommended procedures that still require prior authorization from the carrier as does any repeat of a failed surgical procedure. Treatments over $1,000 for body parts that are not addressed by the MTG also still require prior authorization.

The C-4AUTH form has been modified to accommodate these changes. The C-4AUTH form should not be used to request any MTG treatment that is pre-authorized.

Informal Resolution

There is a voluntary informal mechanism available for discussion and resolution of disputes between the treating medical provider and an insurance carrier or Special Fund. In the event of a variance denial, the treating medical provider is encouraged to contact the insurer or Special Fund (within 8 business days of receipt of a denial) to attempt to resolve the dispute informally, thereby avoiding litigation or Medical Arbitrator review.

Carrier Contact Information for MTG Related Care

Finally, in order to expedite requests for MTG related care, medical professionals should communicate directly with the appropriate carrier contact, when necessary. Carrier Contact information is available on the Board's website. These specific carrier contacts should be utilized to answer MTG questions.

Please contact the Board's Medical Director's Office at (800) 781-2362 if you have any questions.

Jaime Szeinuk, M.D
Medical Director

Robert E. Beloten
Chair