Texas Workers' Compensation

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§ 137.100. Treatment Guidelines

(a) Health care providers shall provide treatment in accordance with the current edition of the Official Disability Guidelines-Treatment in Workers’ Comp, excluding the return to work pathways, (ODG), published by Work Loss Data Institute (Division treatment guidelines), unless the treatment(s) or service(s) require(s) preauthorization in accordance with § 134.600 of this title (relating to Preauthorization, Concurrent Review and Voluntary Certification of Health Care) or § 137.300 of this title (relating to Required Treatment Planning).

(b) Information on how to obtain or inspect copies of the Division treatment guidelines may be found on the Division’s website: www.tdi.state.tx.us.

(c) Health care provided in accordance with the Division treatment guidelines is presumed reasonable as specified in Labor Code § 413.017, and is also presumed to be health care reasonably required as defined by Labor Code § 401.011(22-a).

(d) The insurance carrier is not liable for the costs of treatments or services provided in excess of the Division treatment guidelines unless:

(1) the treatment(s) or service(s) were provided in a medical emergency; or

(2) the treatment(s) or service(s) were preauthorized in accordance with § 134.600 or § 137.300 of this title.

(e) An insurance carrier may retrospectively review, and if appropriate, deny payment for treatments and services not preauthorized under subsection (d) of this section when the insurance carrier asserts that health care provided within the Division treatment guidelines is not reasonably required. The assertion must be supported by documentation of evidence-based medicine that outweighs the presumption of reasonableness established by Labor Code § 413.017.

(f) A health care provider that proposes treatments and services which exceed, or are not included, in the treatment guidelines may be required to obtain preauthorization in accordance with § 134.600 of this title, or may be required to submit a treatment plan in accordance with § 137.300 of this title.

(g) The insurance carrier shall not deny treatment solely because the diagnosis or treatment is not specifically addressed by the Division treatment guidelines or Division treatment protocols.

(h) This section applies to health care provided on or after May 1, 2007.

The provisions of this § 137.100 adopted to be effective January 18, 2007, 32 TexReg 163.

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At a Glance:

Title:

§ 137.100. Treatment Guidelines

Title:

Title 28. Insurance

Status:

Current

Usage:

New Law Rule

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