Frequently Asked Questions About the MTG Additions and Improvements
What is included in the 2013 Medical Treatment Guidelines Additions and Improvements?
Guidelines for the treatment of Carpal Tunnel Syndrome
An ongoing maintenance care program of PT, OT or spinal manipulation for patients who meet specified criteria.
Regulatory and process changes.
What is an ongoing maintenance care program?An ongoing maintenance care program is a course of treatment that may include PT, OT or spinal manipulation, depending on the body parts involved. In certain circumstances, an ongoing maintenance care program may be indicated to maintain a patient’s functional status if there has been a previously observed and documented (in the medical record) objective deterioration in functional status without the identified treatment
Who is eligible for this program?To qualify for ongoing maintenance care, the patient must have:
reached maximum medical improvement (MMI) and have a permanent disability
demonstrated a decline in functional status without the identified treatment
Specific, objective functional goals must be identified, measured and met in order to support the need for ongoing maintenance care. There is a limit of 10 visits per year when the criteria for the program are met. A variance for additional treatment is not permitted.
What documentation is required for participation in the ongoing maintenance care program? The criteria that must be met and documented include:
Patient participation in a self-management program developed jointly with the provider;
Worsening of symptoms (function and pain) despite the self- management program;
Initiation of the ongoing maintenance program with specific objective functional goals that are identified, measured and met as a result of the maintenance treatment.
The provider must establish, with documentation in the medical record, that the previous treatment maintained functional status and that, without treatment, functional status deteriorated. The need for ongoing maintenance treatment must be evaluated periodically by progressively longer trials of therapeutic withdrawal of maintenance treatment. Within a year, and annually thereafter, a trial without the maintenance treatment should be instituted. If deterioration in functional ability is documented during the therapeutic withdrawal, reinstatement of the ongoing maintenance care program may be acceptable.
Who is authorized to provide treatment in an ongoing maintenance program?Depending upon the injured body part(s) one of the following may be authorized to provide treatment: a physician, chiropractor, physical therapist or occupational therapist. Only one provider may develop a course of treatment that meets the criteria for on maintenance care program for a particular body part.
Is a variance request or C-4 Authorization required for an ongoing maintenance care program?No. Ongoing maintenance care provided consistent with Guideline criteria does not require a variance or C-4AUTH. There is a limit of 10 visits per year when the criteria for the program are met. A variance for additional treatment is not permitted.
Can a variance request be submitted once the maintenance program is completed?No. There is a limit of 10 visits per year. No variance for additional treatment is allowed.
When would treatment for an exacerbation be appropriate? What documentation is required?An exacerbation is a temporary worsening of a prior condition by an exposure or injury. This results in a transient increase in symptoms and signs, and a decrease in function. Treatment allows the patient to recover to baseline status or what it would have been had the exacerbation not occurred.
The initial treatment of an exacerbation that fulfills the requirements for an exacerbation and is consistent with the applicable MTG recommendations and General Principles does not require a variance. (See MDO Bulletin on Treatment of Exacerbations, January 4, 2012, for exacerbation requirements)
If a variance request for additional therapy or maintenance care was previously denied based on the 2010 Guidelines, would the patient be eligible for an ongoing maintenance program? Potentially yes, but only if the patient meets all ongoing maintenance care program criteria. However, maintenance of function (i.e.: no documented evidence of objective deterioration in function) in the absence of intervening PT, OT or chiropractic treatment will be considered when evaluating whether the requirements for ongoing maintenance care have been met.
If the case is established for multiple body parts, for example the back and knee, are 10 visits allowed for each body part or 10 in total?If an established case for multiple body parts meets the requirements for ongoing maintenance care for each site, the patient is entitled to up to 10 visits for each body part. For example, 10 visits could be allowed for chiropractic treatment of the back and 10 visits for physical therapy for the knee. If multiple body parts were treated on the same day, each treatment would count as one visit for each body part. If only one body part was treated, then it would count as one visit, for the body part treated.
To be eligible for ongoing maintenance care, there must be a determination of MMI and a permanent disability. Who is responsible for making that determination? This requirement is satisfied if:
a judge has found that the claimant has reached MMI and has a permanent disability, or
(in the absence of a judicial finding) the attending physician or chiropractor documents that the patient has achieved MMI and has a permanent disability, using the designated Board form (C-4.3).
Will a claimant who has settled a claim by either a Sec 32 agreement approved by the Board or a lump sum settlement and who continues to be entitled to payment for necessary medical treatment be eligible for ongoing maintenance care?
The claimant will be eligible for ongoing maintenance care if the claimant is medically eligible for ongoing maintenance care (see Q.3), the settlement agreement provides that the carrier or Special Fund remains responsible for medically necessary care and:
the claimant was found to have a permanent disability prior to the settlement; or,
the permanency finding is included in the settlement, or
if the settlement agreement does not include a finding of permanency, the treating provider completes and submits medical documentation that the patient has reached MMI and has a permanent impairment.
If the patient is allowed 10 visits for ongoing maintenance care per year, when does the year start? If all the criteria for maintenance care are met, a maximum of 10 visits are allowed per calendar year regardless of when the claimant reaches MMI.
Are there procedural changes that will be implemented as part of the MTG improvement program beginning 2/1/2013? Yes. The following changes have been made to the variance/pre-authorization process:
Partial variances can be granted.
Variance requests must be submitted within two business days of preparing and signing the request.
Variance denials are resolved by a medical arbitrator, unless the claimant or insurer requests a hearing.
Submission of duplicate variance requests is prohibited when:
time has not expired for the review of the initial request or
new medical information to support the resubmission request has not been provided.
Variance requests that are substantially similar to previously submitted requests can be denied by the carrier on that ground alone, without obtaining a new medical opinion on the need for such treatment. The Board may refuse to issue an order of the chair for a substantially similar request submitted while one is pending or without new medical information.
Anterior acromioplasty and chondroplasty have been removed from the list of procedures that require pre-authorization.
When is a variance request denial resolved by a medical arbitrator instead of in a hearing before a workers’ compensation law judge? How has the process changed?A request for review of a variance denial is directed to medical arbitration unless the claimant or the insurer requests review by a workers’ compensation law judge. The request for review by a medical arbitrator or a law judge may be made on a case-by-case basis.
When using form C-8.1 to object to payment of a bill based on failure of the provider to meet the criteria for ongoing maintenance care, which reason for the objection should be cited? The box for Treatment provided was not based on correct application of the Guideline should be checked.
What changes have been made to workers' compensation forms?The MG-2 and MG-2.1 have been revised based on the procedural changes listed above.
Section C: Provider certifies that the variance request is being submitted within two days of preparation and signing.
Section C: Provider certifies that he or she does not have a substantially similar request pending and that this request contains additional supporting medical evidence if it is substantially similar to a prior denied request.
Section E: A checkbox for Granted in Part, Burden of ProofNot Met and Substantially Similar RequestPending or Denied has been added to the Carrier/Employer’s Response section.