1. 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).
  2. 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.
  3. 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.
  4. What form is used when provider is requesting authorization
    C-4AUTH (Attending Doctor's Request for Authorization and Carrier's Response)
  5. 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.
  6. 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.
  7. 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.
  8. 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.
  9. 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.
  10. 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.
Card Set
Overview of MTG