What Is California Labor Code §4604.5: MTUS Presumption and Visit Caps?

(a) The recommended guidelines set forth in the medical treatment utilization schedule adopted by the administrative director pursuant to Section 5307.27 shall be presumptively correct on the issue of extent and scope of medical treatment. The presumption is rebuttable and may be controverted by a preponderance of the scientific medical evidence establishing that a variance from the guidelines reasonably is required to cure or relieve the injured worker from the effects of his or her injury. The presumption created is one affecting the burden of proof.

What does California Labor Code 4604.5 do?

Labor Code 4604.5 makes MTUS treatment guidelines presumptively correct, and it caps three kinds of therapy visits at 24 each per injury.

The Medical Treatment Utilization Schedule, or MTUS, is a set of treatment guidelines. The administrative director adopts it under Labor Code 5307.27. Section 4604.5 tells doctors, claims adjusters, and workers' compensation judges how much weight those guidelines carry.

Under subdivision (a), the guidelines are presumed correct. They are presumed correct about how much treatment a worker needs, and what kind. That presumption is not absolute. A treating doctor can challenge it with strong medical proof.

The presumption reaches broadly. It covers nearly every treatment request measured against the MTUS. A separate rule inside the same law reaches more narrowly. That rule caps three specific types of therapy visits. The cap starts with injuries on or after January 1, 2004.

How can a doctor rebut the MTUS presumption?

A doctor can rebut the presumption with strong medical evidence that outweighs the treatment guideline.

Subdivision (a) sets the legal test. The side asking for care outside the MTUS carries the burden of proof. A doctor's report must do more than disagree with a guideline. It needs real medical evidence. That evidence must outweigh the guideline. Simply balancing it is not enough.

The state's Division of Workers' Compensation describes two narrow situations for care outside the schedule. One: the MTUS guideline does not address the worker's condition. Two: the treating doctor rebuts the guideline with better evidence. Outside those two situations, the guideline controls the request.

What is the 24-visit cap on chiropractic, occupational therapy, and physical therapy?

Each of three therapy types is capped at 24 visits per industrial injury.

The cap applies to injuries on or after January 1, 2004. Labor Code 4604.5 allows no more than 24 chiropractic visits per injury. It allows no more than 24 occupational therapy visits per injury. It allows no more than 24 physical therapy visits per injury. The limit runs with the injury, not the calendar. It does not reset every January.

Each visit type is tracked on its own. Using up the physical therapy visits does not reduce the chiropractic visits. It does not reduce the occupational therapy visits either.

When does the 24-visit limit not apply?

The limit steps aside for written employer authorization and for postsurgical physical medicine.

Two situations take a visit outside the count. First, an employer can authorize more visits in writing. These are extra physical medicine visits beyond the usual allowance. Paying for extra visits once does not waive the limit for a later request. Lawmakers added this written-authorization rule through Senate Bill 863 in 2012. It became effective on January 1, 2013. The statute itself says this addition only clarifies rules that already existed.

Second, postsurgical physical medicine visits do not count at all. The same is true for postsurgical rehabilitation visits. They must follow the postsurgical treatment schedule. The administrative director adopts that schedule under Labor Code 5307.27.

What happens if the MTUS does not address the injury?

Subdivision (d) sends that claim to other treatment guidelines that are evidence based and nationally recognized.

Not every condition has its own MTUS guideline. When that happens, subdivision (d) applies. Treatment must then follow other medical guidelines. Those guidelines must be evidence based. They must be scientifically grounded. They must be recognized across the national medical community. The MTUS itself leans heavily on guidelines from the American College of Occupational and Environmental Medicine, known as ACOEM. A condition without its own ACOEM-based rule is the kind of gap subdivision (d) fills.

How does the MTUS presumption connect to utilization review and independent medical review?

A disputed request is usually decided first through Utilization Review. Independent Medical Review comes next if it is denied.

A request that leans on subdivision (a) often starts the same way as any other. So does a request that runs into the 24-visit limit. Both go through Utilization Review first. See our guide to Utilization Review under Labor Code 4610. Utilization Review, or UR, is the claims administrator's review of a treatment request. A UR denial usually moves to Independent Medical Review next. See our guide to Independent Medical Review under Labor Code 4610.5. Independent Medical Review, or IMR, is decided by a reviewer outside the claims administrator.

A claims administrator may lean on the MTUS to deny or cut back therapy visits. If that happens, ask for the Request for Authorization. Ask for the UR decision too. Ask which guideline the reviewer cited. Track how many visits of each type you have used. The three allowances are counted on their own. If your treating doctor believes you need more visits, say so in the record. The same goes for different care. The report must explain why, and it must point to real supporting evidence. Contact Yazdchi Law P.C., or call (661) 273-1780, to go over a California workers' compensation treatment dispute. The firm reviews each matter individually. For related reading, see our pages on Labor Code 4600 and the MTUS, Utilization Review (Labor Code 4610), Independent Medical Review (Labor Code 4610.5), and what medical treatment California workers' comp covers.