Workers' Compensation

California: The MTUS and Treating Physician Reports

Does Labor Code § 4604.5(a) specifically require the treating physician’s report to cite the applicable Medical Treatment Utilization Schedule provisions?

In Sandoval v. San Diego Unified School District, 2016 Cal. Wrk. Comp. P.D. LEXIS --, the WCAB, affirming the WCJ, held that the medical reports of the applicant’s treating physician, Steven Tradonsky, M.D., and consulting physician, John W. Miles, M.D., constituted substantial evidence to support the WCJ’s finding that the applicant was entitled to medical treatment in the form of right rotator cuff surgery.

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The WCAB held that the physicians’ recommendation for surgery was consistent with the Medical Treatment Utilization Schedule (MTUS) guidelines. The WCAB found that, contrary to the defendant’s assertion, the physicians requesting authorization for medical treatment are not required to specifically cite to the MTUS guidelines or, alternatively, explain why the guidelines are not applicable, in order to comply with Labor Code § 4604.5 [LC 4604.5] and to constitute substantial evidence, when the physician has provided care within the treatment protocols as stated in the MTUS and the additional treatment being requested also complies with the requirements of the MTUS.

Commissioner Razo, while concurring with the conclusion that the medical reports in this case supported the applicant’s need for surgery, did not agree with the majority’ statement that requesting physician’s medical reports need not cite to the MTUS in order to comply with Labor Code § 4604.5 [LC 4604.5].

Commentary:

In Sandoval, the majority of commissioners interpreted Labor Code Section 4604.5(a) to not specifically require the treating physician’s report to cite the applicable MTUS provisions as long as the recommendation was consistent with the applicable MTUS or adequately rebutted the MTUS. The separately concurring commissioner, who was only recently appointed, asserted that the physician’s report must actually cite the applicable MTUS provision.

If the concurring commissioner’s position were the law, then the overwhelming majority of treating physicians’ reports submitted in workers’ compensation cases would not be in compliance. For instance, even if the treating physician discussed all of the relevant findings required by the MTUS, without a citation to the MTUS itself, the report would be found to be inadequate. This would require a fundamental change in the way treating physicians report. There may be other commissioners who agree with this strict interpretation of Labor Code Section 4604.5(a) and it is likely that we are going to see ongoing disagreement between the commissioners as to what constitutes an adequate treatment recommendation.

Read the Sandoval noteworthy panel decision.

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