California Code of Regulations
Title 8 - Industrial Relations
Division 1 - Department of Industrial Relations
Chapter 4.5 - Division of Workers' Compensation
Subchapter 1 - Administrative Director-Administrative Rules
Article 5.5.2 - Medical Treatment Utilization Schedule
Section 9792.27.17 - Formulary - Dispute Resolution
Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(a) Medical Necessity Disputes.
Disputes over the medical necessity of pharmaceutical treatment covered by the MTUS Drug Formulary are governed by the utilization review and independent medical review provisions of Labor Code sections 4610, 4610.5, and regulations at section 9792.6.1 et seq, and section 9792.10.1 et seq.
(b) Formulary Rule Medical Treatment Disputes Other than Medical Necessity Disputes.
Disputes over failure to follow formulary rules, other than medical necessity disputes covered by subdivision (a), shall be resolved through the procedure for non-IMR/IBR disputes set forth in WCAB rules, title 8, California Code of Regulations, section 10451.2, Determination of Medical Treatment Disputes.
1. New section filed 12-7-2017; operative 1-1-2018 pursuant to Government Code section 11343.4(b)(3) (Register 2017, No. 49).
Note: Authority cited: Sections 133, 4603.5, 5307.3, 5307.1 and 5307.27, Labor Code. Reference: Sections 4600, 4604.5, 5307.1, 5307.27 and 5307.29, Labor Code.
