Treatment Authorization Requests: Ensuring Proper Compliance with 12 NYCRR 325-1.4

Workers’ Compensation Law Section 13 establishes the obligation of the employer to “promptly provide for an injured employee such medical surgical, optometric or other attendance or treatment… for such period as the nature of the injury or the process of recovery may require.”

When requesting authorization for treatment, the provider submits a Board form titled, “Attending Doctor’s Request for Authorization and Insurer’s Response.”  The Board code for the form is shortened to C-4AUTH. Unlike a variance request, a request for authorization in a C-4AUTH is for treatment to an established site within the requirements of the Medical Treatment Guidelines. The question with a C-4AUTH is whether the requested treatment is medically necessary.

If it is believed that certain treatments requested by the attending physician are not medically necessary and you wish to deny treatment, you will need to obtain contrary medical evidence to support the denial. As stated by the Board in Amphenol Corporation[i],  the response from the carrier denying the request must contain a report from a doctor authorized to conduct independent medical examinations (IME), or reference a report already in the Board’s record which contains contradictory medical evidence. Submitting a denial to a C-4AUTH request without contrary medical evidence will likely result in the treatment being approved by the Board unless there is a glaring deficiency in the request, such as the doctor failing to meet his or her burden of proof regarding medical necessity.

Under the statute, the carrier must respond to the C-4AUTH with an Attending Doctor’s Request for Authorization and Insurer’s Response Denial (C-4AUTHD) within 30 days of the date the C-4AUTH was sent by the provider. This means that if you wish to get an IME to address the request, it must be obtained within those 30 days. At times, that can be a difficult and tight deadline to adhere to. It also must be remembered that an IME-4 produced in response to a C-4AUTH request must be compliant with all provisions of WCL Section 137. That being said, a new IME is certainly the most credible medical evidence to support a denial of a C-4AUTH.

As previously stated, it is possible to use a report already in the Board file as contrary medical evidence to support a denial. If there is a recent IME that did not specifically address the treatment request, an addendum can be obtained and used as contrary medical evidence. As the Board stated in Amphenol Corp., the previously filed report does not have to be an IME-4, but can also be a report from a treating physician, if that report contains contrary medical evidence to the current request. However, the credibility of the medical evidence should be taken into account when used in support of a C-4AUTHD. If the report is stale or if the physician did not have new or relevant information regarding the treatment, the evidence in support of the denial is greatly weakened. With any previously filed medical report, an evaluation must be made as to whether it properly addresses the treatment request. If not, then a new IME is recommended for the best chance at a successful denial.

[i] No. G0088239, 2018 WL 3322552 (N.Y. Work. Comp. Bd., July 3, 2018)