The New York State Workers’ Compensation Medical Treatment Guidelines

On behalf of The Law Offices of Joseph A. Romano, P.C. on Thursday, June 6, 2019.

The New York State Medical Treatment Guidelines (MTG)

In December 2010, the New York State Workers' Compensation Board implemented a program of medical treatment guidelines (MTG) that fundamentally changed the delivery of health care to injured workers.

The MTG program included four comprehensive, evidence-based guidelines for the treatment of injuries and illnesses involving the neck, back, shoulder and knee. These guidelines are the mandatory standard of care for dates of service on or after December 1, 2010.

On March 1, 2013, the Carpal Tunnel Syndrome Guidelines, updated versions of the current MTGs and a new maintenance care program were adopted. Non-Acute Pain Guidelines as well as updated versions of the current Medical Treatment Guidelines are effective for dates of treatment on or after December 15, 2014.

BODY PARTS/CONDITIONS INVOLVED

Mid and Low Back |

Neck |

Shoulder |

Knee |

Carpal Tunnel |

Non-Acute Pain (long term pain management treatment)

Key Facts

What are Medical Treatment Guidelines? The Medical Treatment Guidelines are the standard of care for treating injured workers in New York, based on the best available medical evidence and the consensus of experienced medical professionals.

Do the Guidelines apply if the injured worker needs emergency treatment? No. The Treatment Guidelines do not have to be adhered to if emergency medical care is required.

What are the benefits of Medical Treatment Guidelines?

The Medical Treatment Guidelines set a single standard of medical care for injured workers and :

  • 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 medical providers over treatment issues,
  • Increase timely payments to medical providers,
  • Reduce overall system costs.

Do the procedures recommended by the Medical Treatment Guidelines require pre-authorization if the cost exceeds the $1,000 threshold?

No. The $1,000 pre- authorization threshold does not apply and consent by the insurance carrier is not required. Health care providers may treat without pre- authorization; however, the care must be consistent with the Guidelines.

Certain conditions do require pre-authorization, such as those listed below:    

  • Lumbar fusions
    • Artificial disk replacement
    • Vertebroplasty
    • Kyphoplasty
    • Electrical bone growth stimulators
    • Spinal Cord Stimulators
    • Osteochondral autograft
    • Autologous chondrocyte implantation
    • Meniscal allograft transplantation
    • Knee arthroplasty (total or partial knee joint replacement)
    • 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.

What should a medical provider do if he or she believes an injured worker needs treatment that is not consistent with the Guidelines?

A treating Medical Provider may submit a variance request for exceptions to the Medical Treatment Guidelines. He or she must  use form MG-2, to address legitimate medical reasons to depart from Guidelines, such as those listed below:

    • To extend the duration of treatment when an injured worker is continuing to show objective functional improvement.
    • Individual circumstances, such as adverse medical conditions of the injured worker require a different treatment protocol be implemented.
    • Actual treatment required is not addressed by the Guidelines.
    • Peer reviewed studies provides evidence supporting new/alternative treatments.

Medical Treatment Guideline Variance Request

When to submit a Variance Request

A variance request should be submitted when a treating medical provider needs to request treatment that is not consistent with the Medical Treatment Guidelines (MTG).

This includes requests to extend treatment beyond the maximum duration or frequency recommended in the MTG, or requests for treatment that is not recommended or not addressed in the MTG.

A variance must be requested and approved before treatment is provided.

How to Submit a Variance Request

  1. Complete:
  2. Search for the insurance carrier's designated contact
    • Note: Failure to submit the request to the designated contact identified on the Workers' Compensation Board website may result in your request being denied.
  3. Within two (2) business days of the date the form is prepared:
    • Fax or email the form to the insurer's designated fax/email address. If you are unable to send or receive fax or email, mail the form with a return receipt requested. If the Claim Administrator (Insurer or Third Party Administrator) asks that an alternate contact be used, identify the alternate contact on the form and send the request to both the designated and alternate contact..
    • On the same day also send a copy to the:
      • Workers' Compensation Board using one of the prescribed methods of same day transmission (fax, email or Web Upload).
      • patient and the patient's legal representative if any.

TREATMENT TO NON-MTG BODY PARTS/CONDITIONS

Written authorization must be obtained by submitting Form C-4AUTH for special service(s) costing over $1,000 in a non-emergency situation or requiring pre-authorization pursuant to the Medical Treatment Guidelines (MTG). With limited exceptions, care that is provided consistent with MTG recommendations does not require pre-authorization. Pre-authorization is only required for the 11 procedures and second surgeries listed in the Medical Treatment Guidelines for the Mid and Low Back, Neck, Shoulder, Knee, Carpal Tunnel Syndrome and Non-Acute Pain.

How to Request Authorization

  1. Complete:
  2. Search for the insurance carrier's designated contact.
    • Note: Failure to submit the request to the designated contact identified on the Workers' Compensation Board website may result in your request being denied.
  3. Fax or email the form to the insurer's designated fax/email address. If you are unable to send or receive fax or email, mail the form with a return receipt requested. If the Claim Administrator (Insurer or Third - Party Administrator) asks that an alternate contact be used, identify the alternate contact on the form and send the request to both the designated and alternate contact.
  4. Send a copy to the Workers' Compensation Board, the patient's legal representative if any, or the patient if they are not represented.

Please note It is the attending physician's burden to set forth the medical necessity of the special services required. This information must be provided in the Statement of Medical Necessity section of the form. 

SPECIAL SERVICES - Services for which authorization must be requested are as follows:

  • Physicians - To engage the services of a specialist, consultant, or a surgeon, or to provide for X-ray examinations or physiotherapeutic or other procedures, or to provide for special diagnostic laboratory tests costing more than $1,000.
  • Podiatrists - In treating the foot, to provide physiotherapeutic procedures, X-ray examinations, or special diagnostic laboratory tests costing more than $1,000.
  • Chiropractors - In treating a condition as provided in Section 6551 of the Education Law, to engage the services of a specialist, consultant, or a surgeon, or to provide for X-ray examinations or physiotherapeutic or other procedures, or to provide for special diagnostic laboratory tests costing more than $1,000.
  • Occupational/Physical Therapists - In treating a condition as provided in Article 136 or 156 of the Education Law, in the Workers' Compensation Law, and the Rules of the Chair relative to Occupational/Physical Therapy Practice to provide a course of occupational/physical therapy procedures costing more than $1,000.
  • Psychologists - Prior authorization for procedures enumerated in section 13-a(5) of the Workers' Compensation Law costing more than $1,000 must be requested from the self-insured employer or insurance carrier. In addition, authorization must be requested for any biofeedback treatments, regardless of the cost, or and special diagnostic laboratory tests which may be performed by psychologists. Where a claimant has been referred by an authorized physician to a psychologist for evaluation purposes only and not for treatment, prior authorization must be requested if the cost of consultation exceeds $1,000.
  • Medical Treatment Guidelines - Lumbar Fusions, Artificial Disk Replacement, Vertebroplasty, Kyphoplasty, Electrical Bone Growth Stimulators, Spinal Cord Stimulators, Osteochondral Autograft, Autologous Chondrocyte Implantation, Meniscal Allograft Transplantation, Knee Arthroplasty (total or partial knee joint replacement), Intrathecal Drug Delivery (pain pumps).

Tags: personal injury, workers comp process, Benefits, workers comp 101, hearingloss, law, lawfirm, accidents, injury, medical

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