Medical care under California’s workers’ compensation law

Workers who have been injured on the job are entitled to evidence-based medical treatment under California workers’ compensation laws’ doctors must recommend and perform medical treatments that have been proven scientifically effective for the work injury or illness. To that end, medical professionals rely on California’s medical treatment utilization schedule, which provides guidelines regarding the type, intensity, frequency and duration of treatment for a large number of work injuries.

The guidelines were made part of the workers’ compensation law in 2003, but they apply even to cases that were settled before then. The result is that the MTUS may be utilized in any case, but the assigned claims administrator may continue payment for treatments the patient has become accustomed to for his or her injury in cases decided before 2003.

A claims administrator must authorize necessary medical treatment, even during the investigation of the claim, within one business day from the time the claim is filed. The cost of treatment during the investigation of a claim is typically subject to a $10,000 cap. Additionally, once a claim is approved, visits to chiropractors, occupational therapists and physical therapists are presumptively capped at 24 each, but more visits may be authorized.

Treatment is generally to continue for so long as it is medically necessary. If a doctor recommends treatment that goes beyond the MTUS guidelines, the claims administrator will require evidence indicating the likely effectiveness of the treatment. Utilization review is used to determine whether or not a treatment is medically necessary. If the treatment is not approved after a UR, the next step is an independent medical review. An attorney could work with the claims administrator to seek approval of treatment beyond that outlined in the MTUS or suggest a strategy in the event that necessary treatment is denied.

Source: State of California, “Answers to frequently asked questions about workers’ compensation for employees“, September 12, 2014

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