An injured worker's attending physician will often request a test, such as x-ray or MRI (magnetic resonance image), for diagnostic purposes, even though the BWC claim may be allowed only for a soft tissue injury, such as a sprain. Very frequently, the MCO (managed care organization) will deny such a request on the basis that the attending physian is attempting to treat a nonallowed condition. Generally, under the workers' compensation law, treatment may be approved in a claim only if it is directed towards an allowed condition in the claim. However, Ohio Admin. Code 4123-6-31(F) provides an exception. This rule provides that x-rays, CT (computed tomography) Scans, MRIs and discograms "shall" be paid "*** when medical evidence shows that the examination is medically necessary either for the treatment of an allowed injury or occupational disease, or for diagnostic purposes to pursue more specific diagnoses in an allowed claim. ***."
Effectively, this law allows the injured worker and his or her physician to obtain approval of these types of tests, even when the claim is not allowed for the more serious medical condition the physician is attempting to diagnose. The attending physician still needs to articulate his or her opinion as to the medical necessity of the diagnostic test based upon the injured worker's subjective complaints and the physician's clinical examination findings which developed as a result of the injury or occupational disease. Ohio Adm. Code 4123-6-31(F) is a law injured workers should be aware of when one of these diagnostic tests has been denied by an MCO. Call us today. 614-221-1300.