Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(a)
(1) The
criteria shall be consistent with the schedule for medical treatment
utilization adopted pursuant to Labor Code section
5307.27. Prior
to adoption of the schedule, the criteria or guidelines used in the utilization
review process shall be consistent with the American College of Occupational
and Environmental Medicine's (ACOEM) Practice Guidelines, Second Edition. The
guidelines set forth in the ACOEM Practice Guidelines shall be presumptively
correct on the issue of extent and scope of medical treatment until the
effective date of the utilization schedule adopted pursuant to Labor Code
section
5307.27. The
presumption is rebuttable and may be controverted by a preponderance of the
scientific medical evidence establishing that a variance from the guidelines is
reasonably required to cure or relieve the injured worker from the effects of
his or her injury.
(2) For all
conditions or injuries not addressed by the ACOEM Practice Guidelines or by the
official utilization schedule after adoption pursuant to Labor Code section
5307.27,
authorized treatment shall be in accordance with other evidence-based medical
treatment guidelines that are generally recognized by the national medical
community and are scientifically based. Treatment may not be denied on the sole
basis that the treatment is not addressed by the ACOEM Practice Guidelines
until adoption of the medical treatment utilization schedule pursuant to Labor
Code section
5307.27. After
the Administrative Director adopts a medical treatment utilization schedule
pursuant to Labor Code section
5307.27,
treatment may not be denied on the sole basis that the treatment is not
addressed by that schedule.
(3) The
relevant portion of the criteria or guidelines used shall be disclosed in
written form to the requesting physician, the injured worker, and if the
injured worker is represented by counsel, the injured worker's attorney, if
used as the basis of a decision to modify, delay, or deny services in a
specific case under review. The claims administrator may not charge an injured
worker, the injured worker's attorney or the requesting physician for a copy of
the relevant portion of the criteria or guidelines used to modify, delay or
deny the treatment request.
(4)
Nothing in this section precludes authorization of medical treatment not
included in the specific criteria under section
9792.8(a)(3).
1. New
section filed 12-9-2004 as an emergency; operative 12-13-2004 (Register 2004,
No. 50). A Certificate of Compliance must be transmitted to OAL by 4-12-2005 or
emergency language will be repealed by operation of law on the following
day.
2. New section refiled 4-6-2005 as an emergency; operative
4-12-2005 (Register 2005, No. 14). A Certificate of Compliance must be
transmitted to OAL by 8-10-2005 or emergency language will be repealed by
operation of law on the following day.
3. Certificate of Compliance
as to 4-6-2005 order, including amendment of section, transmitted to OAL
8-10-2005 and filed 9-22-2005 (Register 2005, No.
38).
Note: Authority cited: Sections
133, 4603.5 and 5307.3, Labor Code.
Reference: Sections
4062,
4600, 4600.4, 4604.5 and 4610,
Labor Code.
