Medical Treatment Guidelines

Medical Treatment Guidelines give an injured worker the right of choice in choosing their physician in any field or specialty without the prior approval for the evaluation/consultation through a 1010 Form. Each non-emergency medical care that exceeds $750 which may be requested by the injured workers’ choice of physician must be submitted in accordance with the Medical Treatment Guidelines on a 1010 Form per the Utilization Review Rules.

In 2009, the Louisiana Legislature passed RS 23:1203.1 which provided the process of adopting a medical treatment schedule with the purpose of assisting with the decision-making process regarding proposed medical treatment for the injured worker. The Medical Treatment Guidelines became effective July 13, 2011. All medical providers and insurance companies are expected to use MTG. When the healthcare provider (HCP) is seeking authorization to exceed the $750 statutory limit for medical services, they must complete the LWC-WC Form 1010–Request of Authorization/Carrier or Self-Insured Employer Response form. 

The LWC-WC Form 1010 Sections 1 and 2 must be completed by the requesting health-care provider. The 1010 Form and all supporting medical documentation are faxed to the C/SIF and/or the designated utilization review (UR) representative. The C/SIF must respond in five business days by returning the Form 1010 to the requesting HCP with their decision determination designated in Section 3. 

If the medical documentation submitted with the original LWC-WC form does not sufficiently provide the necessary information to complete the review of the requested medical services, a LWC-WC Form 1010A is initiated by the C/SIF or UR.  The request must be responded to by the HCP within ten business days from the date of receipt. Failure to submit the requested information shall result in a withdrawal of the request for authorization. 

A claim for denied services can be submitted by any aggrieved party to the OWCA Medical Director by filing a LWC-WC Form 1009 Disputed Claim for Medical Treatment appeal with the Office of Workers’ Compensation Administration medical director. This includes any dispute as to whether the recommended care, services or treatment is in accordance with the medical treatment schedule, or whether a variance from the medical treatment schedule is reasonably required. The LWC-WC Form 1009 must be completed and submitted, via mail, to the OWCA medical director along with the LWC-WC Form 1010, Form 1010A (if applicable), and supporting medical documentation. The form must then be filed within 15 calendar days of the date denial by the C/SIF or the date the denial was received. The medical director shall render a decision as soon as is practicable, but in no event, not more than 30 calendar days from the date of filing. A COPY OF THE COMPLETED 1009 MUST BE MAILED TO ALL INVOLVED PARTIES.

All of the above forms are posted on the Louisiana Workforce Commission’s website, www.laworks.net. You can access the form from the numerical listing by clicking on “Downloads,” then on “Workers’ Compensation,” then “Forms–Numerical.”