Submitting a Variance Request
If a treating medical provider determines that medical care which varies from the Medical Treatment Guidelines (MTG) is necessary, a variance request will need to be submitted. For example, when a treatment, procedure, or test was not originally recommended by the MTG but has become appropriate for the injured worker, he or she can then have a variance submitted to the insurance carrier or Special Fund, the Workers’ Compensation Board, or order of the Chair prior to medical care which varies from the MTG can be provided.
This in turn places the burden of proof to establish that a variance is medically necessary or appropriate on the shoulders of the Treating Medical Provider who is making the request.
A Treating Medical Provider who is requesting a variance is required to submit the request in the format prescribed by the Chair to the insurance carrier or Special Fund, Board, claimant, as well as the claimant’s legal team. It is ideal and preferred for the request to be sent to each on the same day; it is required to be submitted no later than two days after it is prepared and signed.
Variance Requirements
For all variances, there are requirements which must be met. These requirements include:
- A medical opinion from the Treating Medical Provider which includes the basis for the opinion that the proposed medical care that varies from the MTG is appropriate for the injured worker.
- A statement that shows the worker’s agreement to the proposed medical care.
- As well as an explanation of why alternatives under the MTG are either not appropriate or sufficient for the road to recovery.
Additionally, where appropriate, claims may include:
- A description of signs or symptoms which show improvements have not been made with the previous treatments provided in accordance to the MTG.
- Should the variance involve frequency or duration of a particular treatment, a description of the functional outcome, as of the date of the variance request, has continued to demonstrate objective improvement from the treatment and is reasonably expected to continue improving with the additional treatment.
To support the variance request, Treating Medical Providers may submit citations or copies of relevant articles and studies published in recognized, peer-reviewed medical journals.
Resubmitting a Variance Request
If a variance request is initially denied by the carrier or Special Fund, it may be resubmitted. The Treating Medical Provider can submit the date of the denial and additional documentation or justification in support of a new variance request. If the variance request is similar to any previous request, it may not be submitted until the carrier or Special Fund has denies any previous variance request.
If there is no need for an independent medical examination (IME) or review of record, the insurance carrier or Special Fund is required to review and respond to the request within 15 days of receipt. Receipt is defined as the date submitted, if submitted by one of the prescribed methods of same-day transmission, or, if sent by regular mail, five business days after the date the Treating Medical Provider requesting variance certified that the form was sent to the insurance carrier or Special Fund.
If the variance request is resubmitted without any additional documentation or justification beyond the prior variance request, the carrier or Special Fund may deny the variance request by specifying that a prior variance request for a similar treatment, procedure, or test has been denied, and the new request does not contain any additional documentation or justification. This denial may occur without a medical opinion by its medical professional, a review of records, or independent medical examination.
When it comes to submitting a variance request, this is merely the tip of the iceberg. This is not something you should take on alone; our attorneys are ready to help you navigate the procedures and processes you will face throughout your workers’ comp case.
