What Types of Medical Care are Covered by Workers’ Compensation?

California has specific regulations on the types of medical care that are covered by the workers’ compensation system. If doctors want to do something that does not fit these guidelines, you may be stuck paying out of pocket.

Below, learn more about this issue and what to do if doctors want to provide a type of treatment that might not be covered by the workers’ compensation system.

What Does ‘Reasonably Required to Cure or Relieve’ Mean?

When a workers’ compensation claim is approved, the injured worker is entitled to payment of all medical care that is “reasonably required to cure or relieve” the symptoms of an injury, as stated in the California Department of Industrial Relations (DIR) guide for injured workers. The treatment must follow scientifically-based medical treatment guidelines.

Medical Treatment Utilization Schedule

California’s workers’ compensation system covers medical treatment that follows the guidelines from the medical treatment utilization schedule (MTUS). These guidelines are published by the DIR. This schedule includes guidelines from other medical associations, like the American College of Occupational and Environmental Medicine.

These guidelines are supported by the best-available evidence, according to the DIR website on the MTUS. This is why the guidelines are updated based on new evidence.

The purpose of the MTUS is to give doctors guidance on appropriate treatment of a workplace injury, including effective treatments for certain injuries, frequency of treatment and other issues. For example, the guidelines cover how doctors can advise workers on remaining active while they recover. The guidelines also explain the kinds of accommodations workers may need to continue working while they recover.

The MTUS also has a drug formulary listing covered drugs that can be prescribed to injured workers.

These guidelines apply to current and future medical care for your injury. Future medical care must comply with these guidelines or it may not be covered.

Review of Treatment Prescribed by Your Doctor

Employers and claims administrators are required to have a utilization review program for deciding whether a treatment is covered by the MTUS.

This often involves an independent doctor conducting a review of treatment prescribed by a doctor. Generally, he or she makes a decision within five working days about whether to approve the treatment. He or she may also decide the treatment needs to be modified.

What if the Doctor Recommends Treatment That is Not Covered?

Doctors sometimes recommend treatments that are not listed in the MTUS. Fortunately, claims administrators are required to pay for treatment that follows other guidelines recognized by the national medical community.

If the treatment is not recognized by other guidelines, you can still do it. However, you will have to pay for it out of your own pocket. Treatments that fall under holistic or alternative medicine are unlikely to be covered by the workers’ compensation system.

Call Berry, Smith & Bartell with Your Workers’ Comp Questions

If you have concerns about coverage of your medical care while on workers’ compensation, you can schedule a free legal consultation with a Fresno workers’ compensation lawyer.

Our firm is dedicated to protecting the rights of injured workers. We have more than 130 years of combined experience and proven record of recovering benefits for injured workers.