What are Medical Treatment Guidelines (MTGs)?
The MTGs are the standard of care for treating individuals with work-related injuries and illnesses in New York State and are based on the best available medical evidence and the consensus of experienced medical professionals.
What are the benefits of MTGs?
- Set a single standard of medical care for injured workers,
- Expedite quality care for injured workers,
- Improve the medical outcomes for injured workers,
- Speed return to work by injured workers,
- Reduce disputes between payers and health care providers over treatment issues,
- Increase timely payments to health care providers, and
- Reduce overall system costs.
Are the MTGs mandatory for all work-related injuries or illnesses?
Use of the guidelines is mandatory for treatment rendered for conditions for which there is a final effective MTG.
Do the guidelines apply if the patient needs emergency treatment?
The MTGs outline the best standard of care but cannot anticipate every emergency clinical scenario. Therefore, if care is needed on an emergent/urgent basis, and is not covered in the MTGs, then the assumption is that the most appropriate clinical care will be rendered.
Do the MTGs apply to all payer types?
Yes. The guidelines apply to all private and municipal self-insured employers, group self-insured trusts, all Special Funds, the State Insurance Fund, and private insurance carriers.
What is the Workers' Compensation Board Medical Director's Office?
The Board's Medical Director's Office (MDO) is comprised of medical professionals and other support staff.
The responsibilities of the MDO include the oversight of all medical issues at the Board, with a key focus on ensuring high quality care and outcomes for injured workers. MDO staff advise on the Board's MTGs, New York Workers’ Compensation Drug Formulary, and medical fee schedules for provider reimbursement; provide expertise to Board leadership on important medical subjects; and help direct training for Board-authorized providers, and other interested parties.
How do I obtain a copy of the Guidelines?
The MTGs are available for download from the Board's website.
How do I use the MTGs?
Health care providers should be familiar with the guidelines and render treatment consistent with the guidelines. The medical information in the MTGs is also incorporated into OnBoard for easy reference. Training on all of the MTGs is available on the Board website.
What is included in the 2022 MTGs additions and improvements?
The Board has developed new MTGs for: hip and groin; foot and ankle; PTSD and acute stress disorder; work-related depression and depressive disorders; work-related/occupational asthma; work-related interstitial lung disease; complex regional pain syndrome (CRPS); traumatic brain injury; and eye disorders. The Board has also updated all of its prior MTGs: neck; mid and low back; shoulder; elbow; carpal tunnel syndrome (now hand, wrist and forearm, including carpal tunnel syndrome); knee and non-acute pain.
Does the Board offer training on the guidelines?
Yes. Free web-based training is available on the Board website. Programs have been designed both medical professionals and non-medical professionals.
Are CE credits available for registered nurses, psychologists, chiropractors, or physical and occupational therapists who wish to take the training?
Registered nurses, psychologists, chiropractors, and physical and occupational therapists have training but will not receive continuing education credits for completing the training at this time. These professionals may want to contact their professional organizations to determine if they can utilize these training programs for professional education credits. In the interim, however, the Board recommends that these professionals take any of the current training courses they feel are appropriate and review the MTGs.
Ongoing Maintenance Care
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
- chronic pain
- 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 or provide a course of treatment that meets the criteria for an ongoing maintenance care program for a particular body part.
Is a variance request required for an ongoing maintenance care program?
No. Ongoing maintenance care provided consistent with guideline criteria does not require a variance request. 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. However, if there is a significant change in the patient’s condition (exacerbation or aggravation), new or additional treatment may be requested based on that change.
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). Treatment that is different, longer than, or more frequent than that described in the MTG would require a variance.
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 patient has reached MMI and has a permanent disability, or
- (in the absence of a judicial finding) the treating health care provider who is permitted to make permanency determinations documents that the patient has achieved MMI and has a permanent disability using the designated Board form (C-4.3).
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 year beginning when the patient meets the criteria for maintenance care. For ease of administration, when maintenance care spans multiple calendar years, insurers and providers may elect to use calendar years as the timeframe for calculating 10 visits per year.
Prior Authorization Request (PAR)
What is considered a special service?
A special service is a complex or invasive treatment that would normally fall under the medical treatment guidelines. However, these treatments always require a PAR:
- Lumbar fusions
- Artificial disk replacement
- Electrical bone growth stimulators
- Spinal Cord Stimulators
- Osteochondral autograft
- Autologous chondrocyte implantation
- Meniscal allograft transplantation
- Knee arthroplasty (total or partial knee joint replacement)
- Sacro-Iliac joint fusion
- Peripheral Nerve Stimulation
- The repeat performance of a surgical procedure due to failure of, or incomplete success from the same surgical procedure performed earlier, and if the medical treatment guidelines do not specifically address multiple procedures.
How do health care providers request procedures within the guidelines that require pre-authorization?
The prior authorization request should be made through OnBoard. The OnBoard system will guide the health care provider through a series of questions to determine which PAR type to submit.
When a surgeon obtains approval for a procedure which has been pre-authorized, and prescribes physical therapy according to the guidelines, does physical therapy require pre-authorization from the insurance carrier?
Physical therapy consistent with the guidelines does not require prior authorization. The surgeon can submit an MTG Confirmation PAR for post-operative physical therapy at the same time they submit the PAR for surgery. For physical therapy to continue beyond what is recommended in the guidelines, the treating health care provider would have to request a Variance PAR.
Why would a provider request prior authorization for body parts, injuries or illnesses that are not part of the guidelines?
The PAR process is used by all Workers' Compensation Board authorized providers when treating body parts, injuries or illnesses not covered by the guidelines to request authorization for services that cost more than $1,000. A provider can submit a PAR for services less than or equal $1,000 on an optional basis.
The guidelines indicate that treatment is authorized (e.g. epidurals and surgery) if the standards are met. Does this mean that a hospital automatically must accept this patient for surgery without written insurer authorization? What happens if the procedure is performed, and the insurance carrier later denies payment to the provider or the hospital?
If treatment for an established body part and condition is consistent with the MTGs, then prior authorization is not required. In addition, providers may pursue submitting an MTG Confirmation PAR prior to performing a procedure. If the provider secures a Confirmation PAR approval, they can provide a copy to the hospital.
Does a surgeon need to obtain prior authorization for repeat surgeries to any body part or only for those body parts covered by the MTGs?
The prior authorization must be requested for any second or subsequent surgery covered by the MTGs or any surgery costing more than $1,000, even if it is not covered by an MTG.
Is there anything health care providers can do if they want assurance that their interpretation of the guidelines is correct, or if they need an approval document for a hospital or other entity?
Yes. The regulations provide for an optional prior approval procedure where the health care provider can submit an MTG Confirmation PAR to the insurance carrier to determine correct application of the guidelines.
Are all insurance carriers and other payer types required to participate in the MTG Confirmation PAR process?
Does an insurer have to respond to the MTG Confirmation PAR?
Can the insurance carrier obtain an IME or records review upon receiving an MTG Confirmation PAR?
No. The insurance carrier must approve or deny the request based upon a review of the medical documentation to determine if the test or procedure is a consistent application of the guidelines.
Who may deny an MTG Confirmation PAR for the insurance carrier?
A denial of an MTG Confirmation PAR must be reviewed by a Level 2 physician and must include the basis for the denial.
Can an MTG Confirmation PAR and an MTG Variance PAR be submitted at the same time?
Yes, if the requests are not for identical treatments. However, each PAR type will have its own associated timeframes for insurer response.
Can the insurance carrier deny the MTG Confirmation PAR while waiting for the results of an independent medical exam?
No. The insurance carrier must approve or deny the request based on the application of the guidelines.
Can physical and occupational therapists submit an MTG Confirmation PAR?
No. The request for an MTG Confirmation PAR for PT or OT services can only be made by the referring health care provider.
When is a variance request denial resolved by the MDO instead of in a hearing before a workers' compensation law judge? How has the process changed?
When a denial or partial approval is based upon an IME, the medical provider may request review by the MDO, unless a request for further action through adjudication is filed by the patient.
In the event a decision is rendered by the MDO, the parties retain the right to file an RFA requesting review of MDO’s decision.
What should a health care provider do if they believe a patient needs treatment that is not consistent with the guidelines?
It is recognized there are legitimate reasons for exceptions to the MTGs:
- Extend duration of treatment when a patient is continuing to show objective functional improvement.
- Individual circumstances, such as other medical conditions, may delay an individual's response to treatment, or make certain treatment appropriate.
- Actual treatment is not addressed by the guidelines.
- Peer reviewed studies may provide evidence supporting new/alternative treatments.
In such cases, the treating health care provider may submit a Variance PAR.
Can the insurance carrier request an IME or records review upon receipt of a Variance PAR?
Yes. The variance process does allow an additional amount of time (up to a total of 30 days) for the insurer to have an IME or record review within five days of the PAR’s submission.
The guidelines indicate a specific number of visits for chiropractic treatment. Does that mean that a chiropractor would have to submit a request for additional visits?
Yes. The chiropractor may submit a Variance PAR to request treatment beyond what is recommended under the guidelines but must document that the patient is continuing to show objective functional improvement that includes, but is not limited to, positional tolerances, range of motion, strength, endurance, activities of daily living, cognition, psychological behavior, and efficiency/velocity measures that can be quantified. If the chiropractic care is being provided for those with chronic pain who meet the criteria for an ongoing maintenance care program, no variance beyond the ten treatments is allowed.
Can physical and occupational therapists submit a Variance PAR?
No. The request for additional therapy can only be made by the referring health care provider.
Can a delegate complete the Variance PAR?
The treating provider can have delegates start a PAR and input all the relevant information. This PAR will be saved as a DRAFT (on the DRAFT tab) and will have to be attested to and submitted by the provider.
Who at the insurance carrier must review the Variance PAR if the insurance carrier intends to deny the request?
For all PARs except medication, if the Level 1 reviewer does not grant in full, it is automatically escalated to the insurance carrier's Level 2 reviewer which must be a physician.
Can an insurer have an informal resolution process for denied variances?
Yes. The Board strongly encourages insurers and treating providers to informally resolve disputes involving the MTGs, including Variance PARs. If the dispute is resolved by informal discussion, the insurer can change their response within OnBoard to Grant after Denial.
If the MTGs clearly indicate that a certain procedure is not recommended, is a request for a variance appropriate?
Yes. The regulations state, "When a treating health care provider determines that medical care that varies from the guidelines, such as when a treatment, procedure, or test is not recommended by the MTGs, is appropriate for the patient, he/she shall request a variance from the insurance carrier or Special Fund". The health care provider must meet the "burden of proof" when seeking a variance.
If a claim administrator requests an IME upon receipt of a Variance PAR, the insurer has 30 days to reply. When does the 30 day period begin knowing that the insurer has five days to notify a provider that it wants an IME to address the variance?
The insurance carrier has 30 days from the date of receipt of the Variance PAR to have the IME performed and respond to the PAR.
Are health care providers permitted to request review of a Variance PAR denial on behalf of the patient?
Yes. Upon receipt of a denial of a PAR by the insurance carrier’s physician (Level 2) or IME, the treating provider may request review by the MDO (Level 3) if the treating provider still believes the variance is appropriate and medically necessary.
Is there a specific form for the treating health care provider to use to document the patient's agreement to the treatment that varies from the MTGs when submitting a Variance PAR?
There is no specific NYS Workers’ Compensation form that providers use in obtaining consent for treatment that varies from the MTGs. However, there is an attestation which is included in the submission process for a Variance PAR.
What is the process for a patient to file for review from a Variance PAR denial? Is there a form the patient must use to request such review?
The patient may request resolution by adjudication by filing a Request for Further Action (Form RFA-1W).
Can health care providers provide treatment that is not consistent with the MTGs without submitting a Variance PAR?
No. The MTGs are the standard of care in New York State. If one wishes to provide medical treatment that is not consistent with the MTGs, the treating health care provider must submit a Variance PAR to the insurer. If the Variance PAR is not approved by the insurer or by the WCB, then the treatment is not authorized and should not be provided.
Does a physical therapist keep the patient on program or discharge care while waiting for the status of the Variance PAR?
The treating health care provider should submit a Variance PAR as early in the treatment program as possible and avoid waiting until treatment is complete, if it is clinically appropriate. According to the MTGs regulations, "When a treating health care provider determines that medical care that varies from the MTGs, such as when a treatment, procedure, or test is not recommended by the MTGs, is appropriate for the patient and medically necessary, he or she shall request a variance from the insurance carrier or Special Fund by submitting the form prescribed by the Chair for such purpose. A variance must be requested before medical care that varies from the MTGs is provided to the patient and a request for a variance will not be considered if the medical care has already been provided".
What steps are necessary if the insurer wants to obtain an IME after receiving a Variance PAR?
Step 1: If the insurer wants to schedule an IME, the first step is to respond within 5 business days of receipt of the MTG Variance PAR
Step 2: When the IME report has been completed, the insurer must then provide a final response to the PAR within 30 days of receipt of the PAR. The insurer must state the basis for the denial in detail and attach the IME report or identify the IME report by document identification number and the date received by the Board if the IME report is already in the Board's electronic file (12 NYCRR 324.3[b] and ).
It should be noted that the process for obtaining the IME and notifying parties has not changed.
What is the "burden of proof" for a provider seeking a variance?
There are three basic types of variance requests. The provider must present documentation showing that the proposed treatment, which may be:
- An extension beyond the maximum duration or frequency recommended in the MTG,
- Not recommended in the MTGs, or
- Not addressed in the MTG as medically necessary and likely to be effective for the patient.
The documentation required varies depending upon the type of variance (treatment) the provider is seeking. To satisfy the burden of proof, the provider must meet the documentation requirements for the type of variance requested.
All Variance PARs must include:
- A medical opinion stating why the proposed care is appropriate and medically necessary for the patient
- Certification by the requesting provider that the patient agrees to the proposed care, and
- An explanation why alternatives under the MTGs are not appropriate or sufficient
Additionally, requests to extend treatment beyond recommended maximum duration/frequency must include:
- Objective evidence that the requested treatment has produced functional improvement,
- Further improvement is reasonably expected with additional treatment. Documentation should include explanation as to why treatment has not produced maximum effect and
- Proposed plan for additional treatment with the treatment duration and frequency, and functional goals
Finally, for treatment or testing that is not recommended or not addressed, the following must be documented:
- A description of any signs or symptoms which have failed to improve with previous treatments provided according to MTG recommendations.
- Proposed treatment plan and an explanation of why proposed treatment or testing is necessary at this time, including specific functional goals, if applicable.
- Medical evidence in support of efficacy of the proposed treatment or testing – may include relevant medical literature published in recognized peer reviewed journals.
What information should an insurer include if it objects because a provider has not met the "burden of proof?"
All denials for medical reasons, must include a medical rationale. Visit the OnBoard training page for payers to learn how to respond to a PAR.
If durable medical equipment is not addressed in the guidelines, is a variance request required in order for the item to be supplied to the patient?
A DME PAR should be submitted if the DME item does not meet the criteria in the guidelines. When creating the PAR, the provider will be required to enter the appropriate MTG reference code (if MTG related) and should include rationale for why the item is appropriate.
In the "Treatment Approaches" section of the General Principles of the guidelines, (section A.18) it describes what is included in a functional capacity evaluation and it states, "In most cases, the question of whether a patient can return to work can be answered without an FCE." Does that mean that an FCE can be performed without requesting a variance?
The General Principles describe a functional capacity evaluation to be a comprehensive or more restricted evaluation of the various aspects of function as they relate to the patient's ability to return to work. An FCE can be performed without requesting a variance if it is clinically appropriate for the patient consistent with the General Principles of the MTGs, the guidelines, and the criteria outlined in the Official New York Workers' Compensation Medical Fee Schedule ground rules.
If eight weeks of treatment is recommended under the guidelines, does the patient have to been seen during consecutive weeks within that eight-week period, or can the weeks be broken up due to patient no-shows, cancellations, vacations, or illness?
The duration time frames that are recommended in the guidelines are consecutive. If the recommended duration time frame is eight weeks, then treatment beyond the eight weeks would require a variance request.
Whether, pursuant to 12 NYCRR 324, 1(d) 3, a Utilization Review Accreditation Commission (URAC) certified utilization review organization providing variance request services in NYS through an employee who is a registered professional nurse licensed in NYS and which organization is retained by a TPA under contract with an insurer, Special Fund or self-insured employer meets the regulations definition of "an insurance carrier or Special Fund's medical professional"?
There is no restriction on who a Level 1 reviewer must be, however, if it is a Level 2 review it must be a physician (as per 12 NYCCR Part 441.1(g)).
Are insurance carriers required to comply with the MTGs?
Yes. The regulations require insurance carriers to incorporate the MTGs into their policies, procedures, and practices and report their compliance to the Workers' Compensation Board. The regulations require that insurers must pay providers for services rendered in accordance with the guidelines.
Can an claim adjuster approve treatment or does it need to be reviewed by a medical professional?
Approvals or denials can be made by the insurer at either Level 1 or Level 2 of the PAR process. There is no restriction on who a Level 1 reviewer must be, however, if it is a Level 2 review it must be a physician (as per 12 NYCCR Part 441.1(g)).
Which insurer(s) must respond to MTGs PARs in claims involving MTGs where it has not yet been decided which insurer(s) is/are liable for payment?
OnBoard will automatically forward the request to the appropriate payer for review based on the insurer's eClaims sender number that is on file for that claim. If there is no sender number found, the PAR will be subject to a manual review by the Board and will be forwarded once the correct payer is determined.
Which insurer(s) must respond to PARs in claims involving multiple insurers who have been deemed liable for payment?
OnBoard will automatically forward the request to the appropriate insurer with the greatest percentage of apportionment to respond to the request.
Billing & Payment
What recourse does a health care provider have if treatment is rendered in accordance with the guidelines and does not receive payment or a response from the insurance carrier?
If there is no response or payment within 45 days from the date the insurance carrier receives the bill, the health care provider may submit a Request for Decision on Unpaid Medical Bill(s) (Form HP-1.0) through OnBoard.
What if the insurance carrier objects to a bill due to guideline issues?
If an insurance carrier objects to a bill stating that the medical treatment was an incorrect application of the guidelines, was not consistent with the guidelines, or exceeded the approved variance, a C-8.1 form must be timely filed with the Board and the health care provider. The objection will be decided through the Board's adjudication process.
Can health care providers provide treatment that is not consistent with the MTGs by billing the patient's group health plan or charging the patient directly?
No. The Workers' Compensation Law prohibits health care providers from charging patients directly or from billing another health insurance plan for any treatment of an injury that is covered by workers' compensation.
Prior to the guidelines, thermal treatments were "bundled" and not reimbursed. The guidelines suggests that this passive treatment is a legitimate treatment. Is this treatment reimbursable?
If the services rendered are consistent with the guidelines and the appropriate CPT code is listed in the fee schedule for use by the provider, services are reimbursable subject to the assigned RVU and limitations in the fee schedule.
Can a patient voluntarily pay a health care provider for medical treatment that is not recommended in the MTGs?
No. patients cannot pay for medical treatment for workers' compensation injuries or illnesses.
If a chiropractor and physical therapist are providing treatment on the same day which is consistent with the MTGs and billing in accordance with the physical medicine and chiropractic fee schedule ground rules, will both practitioners be paid for the services rendered?
If a patient is treating with a chiropractor and a physical therapist and they both bill modality CPT code(s) that are subject to the RVU per day limitations in the Fee Schedule, both may not be paid. The insurer may object to the bills based on concurrent care. The treating providers may request arbitration, and the arbitration panel will decide if the services rendered were duplicative. If the physical therapist and the chiropractor are providing different treatments, it would not be considered concurrent care.
What changes have been made to workers' compensation forms?
Treatment/Testing PARs are replacing paper forms Attending Doctor's Request for Optional Prior Approval and Carrier's/Employer's Response (Form MG-1), Attending Doctor's Request for Approval of Variance and Carrier's Response (Form MG-2) and Attending Doctor's Request for Authorization and Carrier's Response (Form C-4AUTH). These forms can no longer be used to request authorization for treatment or testing. Health care providers will not need to know what type of PAR to submit, instead they will answer questions based on the treatment/testing needed and the type of PAR will be determined based upon the information they provide. Treatment/Testing PARs submitted through OnBoard will automatically be routed to the appropriate claim administrator for review.
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.
Why are physical and occupational therapists not included in the definition of "treating health care provider" so they cannot request MTG related PARs?
When physical therapy is prescribed by the treating physician/NP/PA, the MTGs require a re-evaluation of the patient within two to three weeks of the initial physical therapy visit and then three to four weeks after the initial re-evaluation. Re-evaluations may be performed by the physician/NP/PA who ordered the physical therapy or the physical therapist. However, if the physical therapist conducts the re-evaluation, the treatment notes and any report of the re-evaluation must be sent to the treating physician/NP/PA. The re-evaluations are important to ensure that the patient is receiving appropriate/adequate medical treatment and can, therefore, maximally participate in the recommended rehabilitation program. When a patient is proceeding slower than expected, it is important for the physician/NP/PA to have this information, either through personally conducting the re-evaluation or receiving information about the re-evaluation, to insure that any co-morbid medical conditions or any previously unidentified limiting medical problems are identified and actively treated, so that the patient's ability to participate in rehabilitation is maximized. If a physical therapist could request a variance then such communication and proper diagnosis or identification of other conditions would probably not occur. The physician/NP/PA and physical therapist must act as a team caring for the patient. The physical therapist's scope of practice does not include the medical reassessment of the patient and it is the physician's/NP/PA responsibility to ensure that the patient receives maximal medical treatment in order to maximize participation in rehabilitation, and ultimately a more rapid return to work. For these reasons, physical therapists are not authorized to request variances.
Can an insurance carrier designate a physician authorized by the Chair to conduct independent medical examinations (IME) as an insurance carrier's medical professional?
Yes, an insurance carrier can designate a physician authorized by the Chair to conduct IMEs as its medical professional as long as the physician is either employed by the insurance carrier, or has been directly retained by the insurance carrier to review claims and advise the insurance carrier, or is employed by a URAC accredited company retained by the insurance carrier through a contract to review claims and advise the insurance carrier (12 NYCRR §324.1[c]).
Do patients have to obtain diagnostic tests from within a diagnostic network for treatment covered under the MTGs?
Yes. The MTGs have no effect on the insurance carrier's right to direct a patient to their diagnostic network.
If an MRI is consistent with the medical treatment guidelines, must the MRI be performed at a network facility contracted with by the insurer, if the insurer so notifies the patient?
Yes. The MRI must be performed at a network facility if the insurer has contracted with the network facility and if the insurer properly notifies the patient pursuant to WCL § 13-a(7).
Body Parts Not Covered by the Guidelines
How will injuries to parts of the body not covered by the MTGs be handled by insurers?
A PAR must be submitted for any treatment/testing costing over $1,000 for body parts not covered by the guidelines and the insurer has 30 calendar days to respond. For treatment/testing costing $1,000 or less, the provider has the option to submit a PAR and the insurer has eight business days to respond.
Out of State Care
If a patient resides out of state, and is treated by an out-of-state health care provider, do the various MTGs processes apply?
Yes, the MTGs and all PAR-related requirements and processes apply for out-of-state providers.
Do the MTGs change the reimbursement methodology for out-of-state care?
The MTGs do not change the out-of-state reimbursement methodology. More details on reimbursement on out-of-state care can be found in the Medical Fee Schedule Ground Rules. Visit the Medical Fee Schedules page for information on how to obtain the Official New York Workers' Compensation Medical Fee Schedule.
What if the patient changes treating health care providers mid-treatment? Do the timelines and/or number of treatments described in the guidelines (e.g., physical therapy, chiropractic treatment) start again with the new provider?
No, the treatment performed by a subsequent treating provider would be a continuation of the treatment rendered by the initial provider. It is expected that the subsequent provider will access the initial provider's records for continuity of care. If additional service is required beyond the guidelines, the treating provider will have to justify it through the variance process.
Do the MTGs have any effect on the requirements in the Preferred Provider Organization (PPO)?
No. The MTGs have no effect on the insurance carrier's right to require a patient to obtain initial treatment from a health care provider participating in the PPO. Health care providers who are participating in a PPO program must also adhere to the MTGs.
What patient history and physical examination findings must health care providers submit with a PAR?
The patient history and physical examination findings that health care providers must submit will depend on the type of injury and the treatment (or proposed treatment) plan.
In general, health care providers should include ALL patient history and physical examination findings that are relevant to the specific injury, diagnosis and treatment plan.
At a minimum, health care providers must provide sufficient patient history and physical examination findings to demonstrate compliance with the medical treatment guidelines. If the patient history and physical findings do not fully document and demonstrate compliance with the medical treatment guidelines, the PAR may be denied.
How do the MTGs affect radiology facilities?
Imaging studies performed for conditions for which there are MTGs, are governed by the MTGs. This means that if the study is not consistent with the guidelines, then the insurer is not responsible for payment, and the facility cannot bill the patient. The insurer may require a Diagnostic Testing Network be used. A Diagnostic Testing Network Lookup is available on the WCB website.
How is a radiologist with a free-standing diagnostic facility or a hospital, who relies on the treating physician's history and physical examination, supposed to know if the patient's treating physician has followed the appropriate MTG protocols prior to requesting the radiology exam being ordered?
The radiologist may wish to contact the treating health care provider and ask if they ordered the study consistent with the MTGs for the body part in question. The radiologist may also refer to the MTGs or submit a Confirmation PAR.
The patient is referred for physical therapy after a back injury. Physical therapy is provided for three weeks and the patient makes minimal progress. Physical therapy is stopped, and the doctor prescribes pain medication. The acute pain begins to subside. Diagnostic test results are negative, and surgery is not indicated. The patient is referred back to physical therapy. This time the patient does start to improve with physical therapy. Does the first 3 weeks of physical therapy count towards the recommended time frame in the guidelines, or may the therapist start over as if it is a new case?
The treatment frequencies and durations that are outlined in the MTGs, typically start from the date of injury, or some other event (such as post-operative care). In the scenario described, or a scenario where PT is discontinued and then restarted, if the resumption of PT will take the patient beyond the duration, frequency or total number of visits recommended in the MTGs, then a PAR is required.
Can an IME deny care if a patient fails to show improvement while receiving treatment that is listed as "needed" in the guidelines?
An IME cannot deny care. The IME can evaluate and opine based on that evaluation. It is the insurer who may deny a request for care.
Care is not listed "as needed" in the MTGs. The MTGs contain recommendations that are considered the standard of care for patients for the body parts covered by the MTGs. An IME may opine on whether the care requested is consistent with the MTGs recommendations. This means that the care must comply with the MTGs recommendations and General Principles. If a patient fails to demonstrate a positive response to treatment, as defined in the MTGs, which may include treatment necessary to maintain the patients clinical and functional status, then one should consider discontinuing the treatment. If asked to opine on this matter, an IME may state that the care was not clinically indicated.
If a patient's complaints have resolved and the physical examination by the health care provider similarly shows a resolution of previous findings, do the MTGs apply?
If the patient's symptoms and objective findings have resolved, then no further care may be indicated for that specific medical problem. However, in the event of an exacerbation, treatment could be performed consistent with the MTGs.
For initial visits, the guidelines seem to disallow routine X-rays except for rare occasions until several visits later. Often orthopedists will want x-rays the first time the patient is seen. If x-rays were taken, how is this allowed or disallowed?
The guidelines identify clinical history, signs, and symptoms that justify the need for x-rays, and do not recommend them for every new patient, nor for every condition. If the x-rays were taken and did not meet the guidelines criteria, the insurer would have the right to object to payment.
If a treating health care provider refers a patient for eight weeks of physical therapy and it is not medically necessary to see the patient for eight weeks, is the treating health care provider required to see patients for a re-evaluation two-three weeks after the initial visit and three-four weeks thereafter?
The health care provider should see patients as clinically necessary according to the patient's condition and the applicable MTGs.
How do the MTGs apply to Section 32 agreements?
If the agreement does waive the patient's rights to future medical benefits, then the patient will become responsible for paying for future treatment, and while the MTGs may still represent the standard of care, the MTGs will not apply as the Workers' Compensation Board no longer has jurisdiction over the claim.
Can health care providers provide treatment that is not consistent with the MTGs if they do so for free?
No. The guidelines and the variance process determine whether medical services are necessary. If they are not necessary, they should not be provided.
Do I need a PAR for post-operative PT and/or how many post-operative PT visits can I do before I need a PAR?
The clinical indication, frequency and duration of post-operative PT is specific to the body part, injury and surgery as outlined in the MTGs. Treatment beyond or different from that recommended in the MTGs would require a PAR.
Are health care providers required to adhere to the guidelines for No-Fault patients?
The Workers' Compensation Board does not have jurisdiction over No-Fault cases. Inquiries regarding No-Fault cases should be directed to the New York State Insurance Department.
Can physical therapists or chiropractors perform EMG's?
It is recommended and preferred that electrodiagnostic studies (electromyography and/or nerve conduction velocities) in the out-patient setting be performed and interpreted by physicians board-certified in Neurology or Physical Medicine and Rehabilitation. Surface Electromyography (Surface EMG) is not recommended.
If a patient receives home physical therapy prior to outpatient therapy services, do the home therapy visits count towards the amount of physical therapy that is recommended in the guidelines?
Yes. Physical therapy provided in the home setting would count toward the amount of physical therapy that is recommended in the guidelines.
Does MTG apply to claims under the Volunteer Ambulance Workers' Benefit Law and the Volunteer Firefighters' Benefit Law?