From the Desk of Attorney David L. Niefer
PRACTICE TIP: Although the prior authorization requirements set forth at WCL § 13-a(5) do not apply to durable medical equipment (DME), any relevant Medical Treatment Guideline (MTG) provisions still must be met and a request to vary from the MTGs filed by the treating physician if the MTGs do not provide for the DME in question.
In the case of GMC Contracting Group, Inc., WCB G2570171 (12/15/21), a three member Board Panel considered whether the prior authorization requirements of § 13-a(5) apply to durable medical equipment. Relying upon the plain language of the statutory provision, the Board Panel concluded that the prior authorization requirements are not applicable as DME is not “a specialist consultation, surgical operation, physiotherapeutic or occupational therapy procedure, x-ray examination, or special diagnostic laboratory test.” The Board further reiterated that an injured worker is entitled to “medically necessary and appropriate durable medical equipment” for “as long as the nature of the injury or recovery process may require.” Thus, although the cost of a DME might exceed $1,000.00, prior authorization under WCL § 13-a(5) is not required.
The decision in GMC Contracting Group, Inc. was silent with regard to the application of any relevant MTG provisions. In evaluating any medical bill for a DME, a determination should first be made as to whether there is an MTG provision which applies to both the injury site and the DME in question. If the relevant MTG provision does not recommend the DME in question, then it is the treating provider’s burden to file a variance request explaining why the DME in question is necessary despite provisions of the MTG which do not recommend the device in question. Thus, in objecting to a DME bill, the C-8.1 regarding the DME should not reference WCL § 13-a(5), rather the C-8.1 should point to the absence of a variance request and cite to the relevant MTG provision which does not recommend the DME in question.
If you have any questions about this or any other issue, contact David L. Niefer at firstname.lastname@example.org or (607) 723-0600 or any of the attorneys in our office. If you would like a training session on this or any area of the Workers’ Compensation Law, please do not hesitate to contact our firm.
This information is provided for general guidance only. This information should not be used as a substitute for consultation with legal counsel. Each case presents unique facts requiring individual analysis.