Physicians

Proposed Changes to Medical Treatment Guidelines

In an attempt to solidify the legislative changes made by Governor Schwarzenegger, the Department of Industrial Relations has proposed new treatment guidelines. The MTUS (medical treatment utilization schedule) will now replace ACOEM with the DWC’s guidelines. The proposed guidelines are only 26 pages in length. Given the significant impact the proposed changes will have on the authorization of medical treatment, I strongly recommend that you post comments before the deadline of April 8, 2010.

The MTUS remains presumptively correct on the issue of treatment. The MTUS will still be rebuttable by a preponderance of the evidence. Treatment beyond the MTUS will be in “accordance with other scientifically or evidenced based medical treatment guidelines that are nationally recognized by the medical community”. 9792.25.1 (b).

The proposed criteria for rating the quality of studies physicians are required to cite when requesting care outside of the MTUS will now be more complicated and tedious.

Of great concern are the proposed changes regarding Dispute Resolution (Section 9792.25.4). The UR denial of care shall now also be “accompanied by a grading of the overall scientific evidence base that incorporates the new evidence submitted as the basis for the decision”. 9792.25.4 (a) Disputes over the denial of care will still be addressed by LC 4062 and the UR dispute process as defined in 9792.10.

The QME who evaluates the dispute over medical care, “shall consult the DWC registry of quality ratings of scientific evidence to determine if there is a rating of the quality of medical evidence submitted by the requesting physician”. 9792.25.4 (b) (1).

If the registry reflects no postings on the “quality of the medical evidence submitted, the QME if necessary, shall select a specialized consultant from the names of organization approved by the AD.” 9792.25.4 (b) (2) The consultant shall then have 30 days to make a determination on the rating of the scientific evidence.

The QME will then be required to review the consultants recommendations and either adopt or reject the rating of the scientific evidence. A copy of the information provided by the consultant must be attached to the QME report.

The good news is the defendants are required to pay for the review process as a Medical Legal Expense. The bad news is the proposed changes will cause further delay.

The proposed regulations allow the QME to request a panel rating of the scientific evidence “ if necessary”. It appears this caveat will allow QME’s to opt out of the requirement to rate the scientific evidence by committee. As you are aware, the rating of the scientific evidence has been in the Regulations, but not widely followed. Now it appears, the Administration expects the QME’s to more closely follow the guidelines.