How Are Medical Benefits Handled in California Workers’ Comp Cases?

 Posted on June 14, 2021 in Types of Benefits

When people suffer work-related injuries, they are generally eligible for workers’ compensation benefits. Medical costs related to a work injury, disease or illness contracted while working, or a health condition that was caused by the work a person performed should be fully covered. However, there are a variety of requirements that must be met during treatment, and some limitations may apply. Injured workers will want to make sure to understand their rights and the procedures that will be followed as they receive treatment, and they may need to work with an attorney to make sure they receive the medical benefits they deserve.

Medical Care Covered by Workers’ Compensation

When doctors or other medical professionals provide treatment covered by workers’ comp, this treatment must be evidence-based. It must be scientifically proven to be an effective treatment for the injuries that a person experienced while working or due to their work. The California Department of Workers’ Compensation (DWC) maintains a set of regulations known as a medical treatment utilization schedule (MTUS). This schedule provides guidelines for appropriate treatments for different parts of the body, including those related to post-surgery pain treatment and therapy, as well as acupuncture.

A DWC claims administrator must authorize all forms of medical treatment, and they will perform a utilization review (UR) to ensure that a planned course of treatment is medically necessary. The UR will determine whether treatment recommended by a doctor falls within the guidelines of the MTUS. If the recommended treatment is not included in the MTUS or goes beyond the guidelines, the doctor must provide evidence to the claims administrator showing why this treatment will be necessary and demonstrating its effectiveness. 

Decisions about whether to approve recommended treatment must usually be made within five days. However, a doctor may request an expedited review if a person is in a hospital and could possibly die or lose a limb or other major bodily functions without treatment. In these cases, a claims administrator must decide within 72 hours, although decisions may need to be made even more quickly in emergency situations.

In most cases, an injured worker’s medical care will be covered for as long as the treatment is medically necessary. However, there are some limits on certain types of treatment. For example, workers’ comp will cover no more than 24 physical therapy sessions, 24 chiropractic treatments, or 24 occupational therapy visits.

Contact Our San Benito County Workers’ Comp Medical Benefits Attorneys

If you have been denied medical benefits by the Department of Workers’ Compensation, or if you need to address any other issues related to workers’ comp, Cramer & Martinez, LLP can provide you with the legal help you need. We will assist with filing your claim and make sure you follow the right steps when appealing the decisions made by a claims administrator. Contact our Morgan Hill workers’ comp lawyers at 408-848-1113 to set up a free consultation today.

Sources:

https://www.dir.ca.gov/dwc/WCFaqIW.html#MedicalCare

https://www.dir.ca.gov/dwc/FactSheets/FactSheet_A.pdf