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Procedures that require prior approval
- 1 Lumbar fusion
- 2 Artificial Disc replacement.
- 3 Spinal cord stimulators.
- 4 Electrical bone stimulation.
- 5 Vertebroplasty.
- 6 Kyphoplasty.
- 7 Chondroplasty.
- 8 Anterior acromioplasty.
- 9 Autologous chondrocyte implantation.
- 10 Osteochondral autograft.
- 11 Meniscal allograft transplantation.
- 12 Knee arthroplasty (full or partial knee joint replacement).
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Optional Prior Approval
- l The Carrier has 8 business days to respond to this request.
- l The Carrier may either agree or not agree that the treatment is consistent with the MTG.
- l When the Carrier does not agree, the Medical Provider has the further options of
- ¡ reaching out to the Carrier to try and resolve the treatment issue informally or
- ¡ requesting the WCB Medical Director resolve the issue.
- l If a Carrier does not respond to the original request, the Medical Director will issue a resolution.
- Contacts for all Carriers will be listed on the WCB website under Medical Treatment Guidelines section.
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MG1 and MG1.1
l MG-1 (Attending Doctor’s Request for Optional Prior Approval and Carrier’s Response)
- l MG-1.1 (Continuation to Attending Doctor’s Request for Optional Prior Approval)
- ¡ If more than one treatment or procedure is requested at a time, the MG-1.1 may be attached
- to the MG-1.
- ¡ The MG-1.1 should NEVER be submitted without an MG-1.
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What form is used when provider is requesting authorization
C-4AUTH (Attending Doctor's Request for Authorization and Carrier's Response)
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What is a Variance?
Variances allow for flexibility in the MTG. Variances allow Medical Providers to provide treatment that may not be consistent with the Guidelines.
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When are variances used?Variance requests are used in the following circumstances:
- Variance requests are used in the following circumstances:
- l To extend duration of treatment when an injured worker is continuing to show objective functional
- improvement.
- l To treat outside the MTG.
- l For treatment not addressed by the MTG.
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What are reasons the provider may request a variance?
- It is recognized there are legitimate reasons for not adhering to the MTG:
- l People heal at different rates.
- l Extenuating circumstances may interfere with certain treatments or procedures.
- l New studies may show evidence supporting alternate treatments.
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Process for submitting variance:
- Provider submits a Variance Request to the Carrier, the WCB, the injured worker, and the injured worker’s representative, if any. This request includes:
- l Necessary medical documentation to support request.
- l Medical Provider's medical opinion why treatment is appropriate and medically necessary.
- l Injured worker’s agreement to the treatment.
- l Why treatment consistent with MTG is not appropriate or sufficient.
- l If appropriate, signs or symptoms that have failed to improve with treatment consistent with the
- MTG.
- l If the Medical Provider is requesting treatment that exceeds the documented limits in the MTG,
- functional outcomes that continue to show objective improvement and are reasonably expected to
- further improve.
- l Any citations or copies of relevant literature that support the request.
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Carriers response to Variance request
The Carrier reviews the request, determines if there is a need for an Independent Medical Exam (IME), and responds within 15 calendar days without an IME or within 30 calendar days with an IME. (Note: The Carrier must inform WCB and the Medical Provider within 5 business days of the request if it intends to get an IME.) If treatment is denied, the Medical Provider has 8 business days to resolve the issue informally. If no attempt is made or the attempt fails, the injured worker has 21 business days to request a review of the denial by WCB. Note: There are two options for resolving disputes over variance requests. The default option is an expedited hearing. The other option is a review for a final determination by the WCB Medical Director. In order to use this streamlined option through the Medical Director, both the Carrier and the injured worker must waive their rights to a hearing.
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Forms used to request variance
- l MG-2 (Attending Doctor’s Request for Approval of Variance and Carrier’s Response)
- l MG-2.1 (Continuation to Attending Doctor's Request for Approval of Variance and Carrier's Response) ¡ If more than one treatment or procedure is requested at a time, the MG-2.1 may be attached to the MG-2. ¡ The MG-2.1 should NEVER be submitted without an MG-2.
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