EMG/NCV denied by Family practitioner / UR doc? (California)

[chirogeek]

Hi all,

Asked to comment on UR denial of EMG/NCV that was requested by a neurosurgeon and physiatrist--patient is scheduled for ACDF. An out of state Family practitioner has denied it twice and presented non-ACOEM evidence that states EMG/NCV is not accurate enough in the upper extremities for radiculopathy.

Can an out of state family practitioner, MD, deny the test in this situation?

Thanks in advance.

[TC]

The AD adopted the MTUS [medical treatment utilization schedule] in June 2007. The MTUS is entitled to the presumption of correctness. [ACOEM had this presumption prior to the MTUS.] The MTUS is presently primarily composed of ACOEM, but that is about to change.
Reasonable medical treatment is treatment per (1) MTUS, or (2) other scientifically based, nationally recognized, and peer reviewed EBM [evidence based medical] guidelines. Your post indicates the treatment request was denied citing non-ACOEM guidelines. [The guideline is probably not part of the MTUS.]
If the UR was timely, then you have a UR dispute.
UR disputes must go to the AME/QME/panel QME in the case.
That AME/QME/panel QME will opine one way or another, and hopefully s/he will base his/her opinion on the MTUS or other EBM guideline. After receipt of the opinion of the AME/QME/panel QME, the insurer might authorize the test or it might continue to deny it. If the insurer continues to deny it, then you file a DOR for Expedited Hearing, and the WCJ decides the issue per Labor Code 4604.5(a) if the UR denial was per MTUS or 4604.5(e) if the UR denial was not per MTUS.

[TC]

Q: Can UR be performed by an out-of-state doctor?
A: Yes.
AB2969-2008 would have limited Cal. UR to Cal. licensed doctors, but AB2969 was vetoed by the governor 9-30-08.

Q: Is an EMG/NCV within the "scope of practice" of an MD UR doctor?
A: Yes.
Typically, a UR doctor is one of the following: D.C., D.O., or M.D.
An EMG/NCV is within the scope of practice of both a D.O. and M.D.

Q: What is "scope of practice"?
A. Scope of practice is determined by the physician's licensing board and defines the procedures, actions and processes permitted for the licensed individual.

Q: Does the UR doctor have to hold the same license as the requesting physician?
A. No, as long as the reviewer's scope of practice and clinical competence cover the treatment in question.

Q: Does the UR doctor have to be in the same specialty as the requesting physician?
A. No, as long as the reviewer's experience, scope of practice and clinical competence cover the treatment in question.

[postscript2]

Hi Chiro G:

U.R. out of state is as common as Mac N Cheese. Just "cheesier..."

It's usually done by a Nurse and signed off by a doctor. I know this for a FACT, as my last ER "owned" the U.R. company and all responses were conveyed via e-mail to the adjusters by "Nurses!"

My favorite is a Podiatrist, commenting on a cardio condition. I understand your angst, but that's why you are there to break the tie so to speak.

Good luck, take care,

LCS

P.S. to TC: Chiro Geek is a PQME... as well as a treater

[davidd]

Interesting discussion - this story will appear in tomorrow's edition of WorkCompCentral News:

TEXAS: Several workers' comp insurers were fined by the Texas Dept. of Insurance for failing to use Texas doctors for utilization review. This appears to be the first test of a law passed in 2007 that required UR docs to be licensed in Texas. We get reaction from the industry and medical profession.

[postscript2]

Hi DavidD:

I thought that all UR doc's had to be licensed in Cali?

LCS

[davidd]

I might be wrong, but I don't think so. I think TX is the only state that has this requirement.