UR or AME recommensations (California)

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UR or AME recommensations (California)

Postby rosellavera on Wed Jan 26, 2011 3:25 pm

Injured worker see an AME who declares him MMI with provisions for limited future medical care. Injured worker returns to original PTP who recommends treatment not within that recommended by the AME for FMC. Claims is accepted. Does IC send PTP's treatment request through UR or does it deny the treatment as being outside the scope of the recommendations made by the AME?
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Re: UR or AME recommensations (California)

Postby stevepsca on Thu Jan 27, 2011 6:53 am

AME does not control FMC, there is no dispute in FMC to be resolved by AME process.
All medical care is subject to PTP request for treatment, action by CA and UR process.
As usual, if UR denies, go back to AME for resolution process.

In a Stipulation w/Award, there are accepted body parts where FMC is provided. CA could deny based on the stips, again, back to AME for determination to relationship/necessity to org injury.
AME who declares him MMI with provisions for limited future medical care.
Even where an AME might say "IW should have surgery...", doesn't mean it will automatically be authorized.
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Re: UR or AME recommensations (California)

Postby mike@mikeslaw.com on Fri Mar 04, 2011 12:03 pm

A couple of thoughts here.

First, entitlement to medical treatment is an issue of medical fact. As with any medical-legal dispute, the AME is given great weight, but the WCJ is not always compelled to rule based on the AME. From Sullivan On Comp section 5.59:

"AME OPINIONS
There is little doubt that a WCJ should start with AME opinions; an AME's medical report is said to carry great weight.[1] Still, the WCAB recognizes that a WCJ is not required to automatically adopt the AME's conclusions.[2] Although an AME's opinion ordinarily should be followed it may be discarded by the judge if there is good reason to find the opinion unpersuasive. Usually when an AME opinion is disregarded it is because the report somehow does not amount to substantial medical evidence, as discussed in Section 15.58 Evidence at Trial –– Substantial Medical Evidence.[3] If an AME report is disregarded, the judge must explain the reasons for the rejection.[4] In one case, an AME opinion was rejected when the physician offered no reasoning in support of his conclusions and failed to express them in terms of reasonable medical probability.[5] In another case, an AME-turned-defense QME was found to have poor reasoning for his decisions regarding apportionment, and the WCJ ruled based on the treating doctor's report.[6]" Email me if you want the case citations.

Witht that said, the well known Sandhagen case only allows the use of the med legal process on disputes over medical care under specified circumstances. For example, if the UR process approves the treatment, the defense may not turn to the med-legal process to rebut the finding. This is a complex area and is discussed in sectio7.41 Utilization Review –– Dispute Resolution.
Michael Sullivan
Michael Sullivan & Associates, P.C.
Author of "Sullivan on Comp," the clearest and most comprehensive treatise on California Workers' Compensation ever written. More info at http://www.workcompcentral.com/sullivan.
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