Utilization Review Tips
In California’s workers’ compensation system, utilization review (UR) refers to the process of evaluating medical treatment requests to determine their necessity, appropriateness, and adherence to evidence-based medical guidelines.
Utilization review (UR) in California’s workers’ compensation system was established as part of reforms introduced by Assembly Bill 227 (AB 227), signed into law in 1993. This legislation aimed to create a more structured process for evaluating the medical treatment requests of injured workers to improve the efficiency and appropriateness of care.
Subsequent legislation further refined and detailed the UR process, particularly with the enactment of Senate Bill 899 (SB 899) in 2004. This bill brought significant changes to California’s workers’ compensation system, including implementing more specific utilization review standards and procedures.
There are some essential things to remember when requesting authorization for treatment.
The Reviewer typically looks for evidence that supports the request for treatment. This includes clear physical exam findings and details on what treatment modalities the patient has tried and their response to those treatments. It is also very important to document functional improvements to support additional sessions of beneficial treatments.
See this example for a request for additional physical therapy:
“The patient presents with improving neck pain with continued limitations in motion in bilateral rotation and flexion. She has completed a trial of 6 sessions of physical therapy with some improvements in pain, from an 8/10 to 5/10. She reports functional improvements in daily activities, including brushing her hair and working at her desk. Based on these documented improvements and her continued symptoms, an additional course of treatment is indicated.”
See this example for a request for shoulder arthroscopy:
“The patient presents with clinical findings of right shoulder impingement, including a positive Neer’s test and pain in active flexion and abduction. She has failed conservative management to include 12 sessions of physical therapy, a course of NSAIDs, activity modifications, a home exercise program, and a home icing protocol. Additionally, the patient reported some short-term benefits (2 weeks) of pain relief with a subacromial steroid injection, which confirms the presence of subacromial impingement. An MRI of the right shoulder revealed downsloping of the acromion and supraspinatus tendinosis. The patient has failed all attempts at conservative management and is now, based on the guidelines, a candidate for a right shoulder arthroscopy and subacromial decompression. “
See this example for a request for Lumbar MRI:
“The patient presents with low back pain and radicular symptoms in the left L4-L5 dermatome with associated weakness, limitations in forward flexion, and painful extension. She has failed conservative management to include 12 sessions of physical therapy, activity modifications, NSAIDs, and home exercises. At this point, the patient has symptoms that have not improved with conservative attempts as limitations in function and radicular symptoms persist. Based on the guidelines, she should now be afforded a lumbar spine MRI for further treatment planning.”
With your treatment requests, remember to:
Provide Clear Documentation:
Ensure all medical records, treatment history, and relevant documentation are submitted with the request. This should include diagnoses, prior treatments, and results from prior treatment.
Follow Evidence-Based Guidelines
Familiarize yourself with MTUS/ODG. Ensure that your treatment request adheres to these guidelines, and be prepared to provide additional evidence, like supporting research, if MTUS does not address the treatment being requested.
Explain the Rationale
Include a detailed explanation of why the treatment is needed based on your medical condition. Discuss how the treatment will improve your recovery and quality of life.
Highlight Previous Efforts
If applicable, mention any previous treatments and their outcomes and why the requested treatment is appropriate.
Following these tips can improve your chances of successfully navigating the utilization review process and obtaining the necessary medical treatment for your patients.