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Feinberg: Getting to Yes with UR and IMR

By Steven Feinberg

Tuesday, February 7, 2017 | 1439 | 0 | 0 min read

This document is meant to help physicians and others better serve injured workers. Understanding how to write requests for treatment that meet evidence-based medicine (EBM) guidelines will more often result in approved authorization for medical care through utilization review (UR) and independent medical review (IMR).

This approach requires a little extra work at the front end, but it saves having to deal with and respond to denials of care that clog up the physician’s office and take valuable time, leaving the injured worker upset and without treater recommended medical care.

I take full responsibility for this document and any errors or omissions are mine. Your input to improve this document would be greatly appreciated. Please email me at stevenfeinberg@hotmail.com.

This document is not meant to replace the detailed information found on the DWC Workers’ Compensation Website, the medical treatment utilization schedule (MTUS) or the Guide to the MTUS Regulations.

The Division of Workers’ Compensation (DWC) provides a free online education course for physicians treating patients in the California workers’ compensation system. It covers: 1) What the MTUS is and how to use it; 2) How to navigate the MTUS treatment guidelines and apply recommendations via case scenarios; 3) When to consider recommendations outside of the MTUS guidelines for the care of your patient; and 4) The role of utilization review (UR) and independent medical review (IMR) physicians.

The DWC also offers a newly edited and rewritten Physician’s Guide to Medical Practice in the California Workers’ Compensation System (Physician’s Guide). It assists physicians in understanding the many complexities in the California workers’ compensation system and is the basis for the QME exam.

Avoid UR and IME denials by using the MTUS

As a treating physician, you can avoid UR and IMR denials by prescribing medical care that is supported by, and consistent with, the MTUS. The medical treatment utilization schedule (MTUS) is presumptively correct on the issue of extent and scope of medical treatment (Section 9792.21(c)).

The DWC medical treatment utilization schedule (MTUS) outlines the most effective treatment of injured and ill workers, based upon the “best” EBM. The strength (or hierarchy) of evidence search sequence uses EBM-based principles to guide appropriate clinical decision-making when new evidence is produced or when the MTUS does not address a clinical condition or diagnostic test.

Strength (or hierarchy) of evidence guidelines

The DWC MTUS sequence to be followed can be found at medical evidence search sequence.

Treating physicians and medical reviewers shall conduct the following medical evidence search sequence for the evaluation and treatment of injured workers.

  1. Search the recommended guidelines set forth in the current MTUS to find a recommendation applicable to the injured worker's medical condition or injury. (NB: If a treater agrees with and follows the treatment guidelines as documented in the current CA MTUS, there is no need to proceed further).
  2. In the limited situation where a medical condition or injury is not addressed by the MTUS or if the MTUS' presumption of correctness is being challenged, then:
  3. Search the most current version of American College of Occupational and Environmental Medicine or Official Disability Guidelines to find a recommendation applicable to the injured worker's medical condition or injury. If no applicable recommendation is found, or if the treating physician or reviewing physician believes there is another recommendation supported by a higher quality and strength of evidence, then:
  4. Search the most current version of other evidence-based medical treatment guidelines that are recognized by the national medical community and are scientifically based to find a recommendation applicable to the injured worker's medical condition or injury. If no applicable recommendation is found, or if the treating physician or reviewing physician believes there is another recommendation supported by a higher quality and strength of evidence, then:
  5. Search for current studies that are scientifically based, peer-reviewed and published in journals that are nationally recognized by the medical community to find a recommendation applicable to the injured worker's medical condition or injury.

The California Applicants’ Attorneys Association (CAAA) has graciously provided this link to a CAAA Bulletin, MTUS Practice Tips, at #2 MTUS Practice Tip — Strength of Evidence Guidelines, which I highly recommend.

DWC draft MTUS guidelines

The DWC is in the process of updating many of the guidelines and recommendations, and has issued draft MTUS Guidelines Updates, which are accessible now on the DWC website. While not the official “current” Guidelines, as treaters, we are instructed to use the most current evidence-based medicine (EBM).

A draft of the MTUS Guidelines are available at no charge here.

The DWC has proposed draft MTUS Guidelines Updates from American College of Occupational and Environmental Medicine (ACOEM) guidelines (published by Reed Group Ltd.) are accessible as listed below:

The MTUS also contains chapters known as special topics, and these are accessible here:

Current medical treatment utilization schedule (MTUS)

While the following MTUS guidelines are “current” and still in effect, they are “outdated,” and use of the above noted “draft” and Special Topics is recommended.

NECK AND UPPER BACK COMPLAINS (ACOEM Practice Guidelines, 2nd Edition (2004), Chapter 8)

  • In the course of treatment for neck and upper back complaints where acupuncture or acupuncture with electrical stimulation is being considered, use the acupuncture medical treatment guidelines.
  • If recovery has not taken place with respect to pain, use the chronic pain medical treatment guidelines.
  • If surgery is performed in the course of treatment for neck and upper back complaints, the postsurgical treatment guidelines for postsurgical physical medicine shall apply together with any other applicable treatment guidelines found in the MTUS. In the absence of any cure for the patient who continues to have pain that persists beyond the anticipated time of healing, the chronic pain medical treatment guidelines shall apply.

SHOULDER COMPLAINTS (ACOEM Practice Guidelines, 2nd Edition (2004), Chapter 9)

  • If recovery has not taken place with respect to pain, use the chronic pain medical treatment guidelines.
  • If surgery is performed in the course of treatment for shoulder complaints, the postsurgical treatment guidelines for postsurgical physical medicine shall apply together with any other applicable treatment guidelines found in the MTUS. In the absence of any cure for the patient who continues to have pain that persists beyond the anticipated time of healing, the chronic pain medical treatment guidelines shall apply.

ELBOW DISORDERS (ACOEM Practice Guidelines, 2nd Edition (Revised 2007), Chapter 10)

  • In the course of treatment for neck and upper back complaints where acupuncture or acupuncture with electrical stimulation is being considered, use the acupuncture medical treatment guidelines.
  • If recovery has not taken place with respect to pain, use the chronic pain medical treatment guidelines.
  • If surgery is performed in the course of treatment for elbow complaints, the postsurgical treatment guidelines for postsurgical physical medicine shall apply together with any other applicable treatment guidelines found in the MTUS. In the absence of any cure for the patient who continues to have pain that persists beyond the anticipated time of healing, the chronic pain medical treatment guidelines shall apply.

FOREARM, WRIST AND HAND COMPLAINTS (ACOEM Practice Guidelines, 2nd Edition (2004), Chapter 11)

  • In the course of treatment for forearm, wrist and hand complaints where acupuncture or acupuncture with electrical stimulation is being considered, use the acupuncture medical treatment guidelines.
  • If recovery has not taken place with respect to pain, use the chronic pain medical treatment guidelines.
  • If surgery is performed in the course of treatment for forearm, wrist and hand complaints, the postsurgical treatment guidelines for postsurgical physical medicine shall apply together with any other applicable treatment guidelines found in the MTUS. In the absence of any cure for the patient who continues to have pain that persists beyond the anticipated time of healing, the Chronic Pain Medical Treatment Guidelines shall apply.

LOW BACK COMPLAINTS (ACOEM Practice Guidelines, 2nd Edition (2004), Chapter 12)

  • In the course of treatment for low back complaints where acupuncture or acupuncture with electrical stimulation is being considered, use the acupuncture medical treatment guidelines.
  • If recovery has not taken place with respect to pain, use the chronic pain medical treatment guidelines.
  • If surgery is performed in the course of treatment for low back complaints, the postsurgical treatment guidelines for postsurgical physical medicine shall apply together with any other applicable treatment guidelines found in the MTUS. In the absence of any cure for the patient who continues to have pain that persists beyond the anticipated time of healing, the chronic pain medical treatment guidelines shall apply.

KNEE COMPLAINTS (ACOEM Practice Guidelines, 2nd Edition (2004), Chapter 13)

  • In the course of treatment for knee complaints where acupuncture or acupuncture with electrical stimulation is being considered, use the acupuncture medical treatment guidelines.
  • If recovery has not taken place with respect to pain, use the chronic pain medical treatment guidelines.
  • If surgery is performed in the course of treatment for knee complaints, the postsurgical treatment guidelines for postsurgical physical medicine shall apply together with any other applicable treatment guidelines found in the MTUS. In the absence of any cure for the patient who continues to have pain that persists beyond the anticipated time of healing, the chronic pain medical treatment guidelines shall apply.

ANKLE AND FOOT COMPLAINTS (ACOEM Practice Guidelines, 2nd Edition (2004), Chapter 14)

  • In the course of treatment for ankle and foot complaints where acupuncture or acupuncture with electrical stimulation is being considered, use the acupuncture medical treatment guidelines.
  • If recovery has not taken place with respect to pain, use the chronic pain medical treatment guidelines.
  • If surgery is performed in the course of treatment for ankle and foot complaints, the postsurgical treatment guidelines for postsurgical physical medicine shall apply together with any other applicable treatment guidelines found in the MTUS. In the absence of any cure for the patient who continues to have pain that persists beyond the anticipated time of healing, the chronic pain medical treatment guidelines shall apply.

STRESS-RALATED CONDITIONS (ACOEM Practice Guidelines, 2nd Edition (2004), Chapter 16)

EYE DISORDERS (ACOEM Practice Guidelines, 2nd Edition (2004), Chapter 16)

American College of Occupational and Environmental Medicine (ACOEM)

The ACOEM Occupational Medicine Practice Guidelines are published by Reed Group and are available electronically through MDGuidelines, and includes a searchable interface with chapters that are updated with ACOEM's evidence-based methodology. This online tool also provides users with first access to chapters as they are updated.

For physicians handling work comp cases in the state of California, a special discounted rate of $100 per year is available for a period of three years. This offer will be good through Dec. 31, 2017.

Work Loss Data Institute Official Disability Guidelines (ODG)

The current Official Disability Guidelines (ODG) rate is $599 annually. ODG has a generic coupon code, ODGSTATE, which will take 25% off. The California Orthopaedic Association (COA) and The California Society of Industrial Medicine & Surgery (CSIMS) have negotiated coupon codes available in the membership areas of those sites.

Report writing

You can avoid UR and IMR denials by excellence in report writing. Here are some bullet recommendations:

  • Physician needs to provide a clear, legible and concise history and physical examination followed by diagnoses and then recommendations for evidence-based medicine (EBM) care consistent with the MTUS.
  • Timely submitted reports will help expedite proposed treatment and avoid unnecessary delays unrelated to the UR process.
  • Avoid boilerplate paragraphs, especially with an electronic medical record (EMR).
  • State how the medical treatment is supported by the MTUS first. If the treating physician wishes to appeal a denial based upon inconsistency with the CA MTUS, the treating physician can use ACOEM or ODG second, and then with other guidelines or EBM following the MTUS medical evidence search sequence.
  • In your written report, “walk” the claims examiner, attorney, UR or IMR reviewer through the treatment course, and document how the treatment request meets the MTUS EBM standards.
  • The medical reporting should document that the injured worker is educated about, and understands, the diagnoses. Additionally, the treater should outline the specific goals to be achieved. For example: less discomfort (pain); reduced medication usage; improved activities of daily living function; improved sleep; increased ADLs such as personal hygiene, dressing, walking, cleaning, mowing the lawn, etc.; staying at or returning to work modified or full duty.

Report-writing template

Many physicians now use electronic medical record templates but they often include, extraneous, repeated information, and worse — erroneous information. The record must be accurate.

The following is a report-writing template that includes information which can help avoid denials:

  • Brief/concise history: Provide a brief history and keep it short and concise.
  • Current (relevant) symptoms: %uF0A8 Stable %uF0A8 Improving %uF0A8 Worsening.
  • Don’t just repeat the symptoms from the last visit unless still relevant.
  • Physical findings (pertinent): Don’t just repeat the same findings every visit. List only pertinent and relevant positive or changing findings.
  • Current medications: List the actual medications, dose and frequency — be specific as to how may pills taken a day, week or month. Clarify any changes, reason for changes, etc. Ask yourself each visit whether the medication prescribed is truly needed and efficacious.
  • Activities of daily living (ADLs): Note /- or no changes related to treatment. What has changed in a positive way to support the current treatment regimen? Were the goals set at the last visit met?
  • ADL goals (for next visit): Use this section to note what goals are set in terms of ADLs, medication reduction and other activities.
  • Diagnoses (include ICD): Be careful and be specific. While the diagnoses may not change from visit to visit, make sure each visit that they are accurate.
  • Disability status: %uF0A8 MMI/P&S or %uF0A8 TD (temporary disability)
  • Work abilities/restrictions: %uF0A8 Sedentary %uF0A8 Light %uF0A8 Medium %uF0A8 Heavy %uF0A8Very Heavy (check one and elaborate as appropriate — what are the specific restrictions that would allow the IW to return to modified work?)
  • Work status capability: %uF0A8 Stay at Work (SAW) %uF0A8 Return to Work (RTW) %uF0A8 Full duty %uF0A8 Modified duty (with above restrictions).
  • Cannot work in any capacity (total temporary disability — TTD).
  • Treatment plan: Use some common sense. Explain your rationale in simple terms. Make it understandable to the patient, NCM, claims examiner, attorney, UR and IMR reviewers, etc.
  • Prescription/request (RFA): Start simple and conservative before requesting complex and invasive treatments — justify those requests.
  • Request justification/support per MTUS EBM: How will the request for treatment make a positive difference? Is it diagnostic? Will the requested procedure/treatment results in less pain, less medication usage and increased function while avoiding complications? Is the risk-benefit ratio acceptable? How does the request for treatment meet EBM guidelines? Reference the specific MTUS or other guideline (see medical evidence search sequence) or even copy or attach the specific supporting guideline or scientific evidence.

Explanation of the request for initial authorization

The report should contain an explanation that the request/prescription for treatment is to achieve and will result in a positive outcome (and therefore be efficacious) by way of less pain, reduced medication usage and improved activities of daily living — ADLs (including staying at work or returning to work,  SAW/RTW) — which are measured and documented at the next visit.

The report should clearly state that the prescription/request is supported by the MTUS or whatever scientific article or guideline you are using, and is supported by evidence-based medicine or is otherwise justified. If the offered alternative evidence is not of high quality, it may be ignored or rejected.

A “bullet-proof” report would be one that clearly notes that the injured worker has failed prior treatments and shows why the current recommended treatment is appropriate and, when possible, clearly indicates the negative ramifications of not receiving the recommended treatment.

Even if the prescription/recommendation doesn’t quite fit the MTUS guidelines; make sure further details are provided with regard to your request. For example: While the patient has attempted PT in the past without lasting benefit and the prescription is in excess of what the MTUS recommends for this diagnosis, previous PT notes show care consisted primarily of passive modalities.

The newly recommended PT will consist of (list active therapies) that will medically probably result and functional gains and thus should be considered for this specific patient. The more patient specific the treatment plan can be along with justification that treatment will cure or relieve from the effects of the industrial injury and resultant improved ADLs, less medication usage and overall functional improvement, the better chance to obtain authorization.

Explanation of the request for additional/continued treatment authorization

To justify additional or continued treatment, you will have to clearly document how the initial similar treatment resulted in a positive outcome (less pain, less medication usage, increased ADLs, etc.) and why additional similar care will result in a further benefit.

Post-UR and IMR denial

If there has already been a UR denial, a polite reply/appeal should be submitted further explaining your rationale for the request. If you made a mistake and left something out originally, correct and explain the deficiency.

What documentation or evidence or report did the utilization reviewer miss or not consider?

Learn from your UR mistakes. If the UR physician has pointed out legitimate errors in your reporting, correct the deficiency prior to IMR and in all future similar requests. The most common errors are failure to document the appropriate findings and failure to outline the specific reason a particular treatment is appropriate in this individual case.

Documentation is No. 1

It doesn’t really matter where you are in the process — UR, IMR or expedited hearing — every treatment request must be properly documented, fully substantiating the need for the treatment. A treatment request absent adequate documentation equals UR or IMR denial. Getting it right in the first place is the only viable, repeatable strategy.

Documentation specifics

  • Note progression of treatment: Simple/conservative to complex/invasive.
  • Document timeline (how many weeks have passed?).
  • Note failure/lack of improvement with lower level of treatment to date.
  • Distinguish first, second, third and fourth line treatment options.
  • Document history, mechanism of injury (MOI), physical findings, tests and imaging studies that support diagnosis and treatment requested.
  • List red flags that demand treatment and risks associated with denial of care.
  • Document improved ADLs and functional improvement.
  • Document medication reduction.
  • Use the MTUS first and then ODG or ACOEM as a checklist: If the prescription/requested is supported in the guideline, describe how the injured worker meets the requirements for that treatment.

IMR denials and approvals

  • Denial if too early in the treatment course for the specific request without documentation in support of variance from the guidelines, simple diagnosis (sprain, etc.), does not warrant a treatment request. No conservative treatment, red flags, negative physical exam or test will not alter treatment course.
  • Approval if delayed recovery, neurological deficit, chronic condition, conservative treatment didn’t help, positive physical findings.

IMR denial: Remains in effect for 12 months unless:

  • Has there been a substantial change in the patient’s condition — a change in the facts and/or clinical status? Was the IMR determination the result of a plainly erroneous expressed or implied finding of fact?
  • If an IMR denial is in place, are there other alternative treatment options?

This report was compiled by Dr. Steven Feinberg of the Feinberg Medical Group in Palo Alto, California. The report is reprinted here with permission.

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