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Board Finds that Medical Treatment Guidelines Apply to Out of State Claimants

by | Jun 7, 2017 | MAD News |

In a stunning sua sponte reversal of its prior decisions, the Board has found that the Medical Treatment Guidelines apply to out of state treatment.

In the case, Hospice Inc., WCB# 5951 3410, the workers compensation law judge found objections to medical treatment in favor of the providers. The carrier appealed that finding conceding that the Medical Treatment Guidelines do not apply to out-of-state treatment based on the Board’s previous interpretation of application of the guidelines.

The Board, on its own motion and pursuant to its continuing jurisdiction under WCL §123, revisited its prior decisions finding that the Medical Treatment Guidelines did not apply to medical treatment provided to claimants living outside the state. Noting that the guidelines had previously been found to be “instructive” for treatment rendered to claimants living outside the state, and relying on the decision in Kigin v. State of New York Worker’s Compensation Board, 24 NY3d 459 (2014), the board expressly overruled any prior authority to the contrary and found that the guidelines applied to a nonresident claimant’s treatment out-of-state.

The MTGs provide an evidence based medical standard for appropriate medical care. The standards for treatment contained in the MTG ensure that claimants receive the most effective medical care as recommended by best practices in the medical community, and as adopted by the Board in consultation with medical specialists. Such recommended treatment and care should be rendered without regard to the location of the claimant’s home or the medical provider’s practice. As such, the Board Panel finds that the MTGs apply regardless of where or by whom the treatment is rendered.

Given this holding, the board also found that the variance procedure also applies to out-of-state treatment although it refused to require out-of-state providers to use New York Worker’s Compensation board forms. While those are certainly preferred, treatment should not be denied solely as a result of the failure of an out-of-state provider to use the proper form.

Obviously this is favorable from a defense perspective as we can now challenge out-of-state treatment which does not comply with the medical treatment guidelines. Additionally, a provider must satisfy our authorization or variance procedures even though they will not be held to strictly comply with filing of the proper forms.

For a copy of the decision please click on the following link: EBRB-1 finding that MTGs apply out of state_Redacted.