If the injured worker continues to improve, but additional treatment will exceed the guideline recommendations, can the UR nurse approve the treatment?
Yes, the consensus and evidence based documents that the initial licensed reviewer consults to determine whether or not treatment is reasonable and necessary are guidelines, not mandates. The injured worker may require less or more treatment than the guidelines set forth in the MA Treatment guidelines and secondary sources. If the MA Treatment guidelines apply, the UR agent cites the guideline, applies the 10% rule, and sets forth the clinical rationale for approval of services not allowed under the MA Treatment guidelines. If the MA Treatment guidelines do not apply, a secondary source should be cited and the UR agent must set forth the clinical rationale to support the determination.
