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Texas Workers' Compensation: Exceeding Official Disability Guidelines Treatment Recommendations

Posted by attorney Matthew Lewis

If it has been more than two weeks since you sustained a work-related injury in Texas, then you probably have heard about ODG, or the Official Disability Guidelines. This is the book that is used to determine what treatment is automatically approved without asking, and what treatment has to be preauthorized because it is generally not recommended. You've probably also noticed that there isn't very much treatment that is available without preauthorization, and sometimes it is hard to get preauthorization.

The ODG book itself indicates that it is a book of recommendations based on the averages, and that each person will respond differently to treatment and may need more or less than the recommended treatments for any given condition. The book suggests flexibility, but the Division of Workers' Compensation requires "expert medical evidence" to deviate from these guidelines. Expert medical evidence is more than what your doctor says - it is usually some other treatment guideline recommendation or a medical journal article addressing the requested treatment and your condition and symptoms.

Because of the conflict between the book and various states' requirements for deviation from the guidelines, the ODG publisher issued a new chapter on "exception protocols." This is a how-to section on deviating from the guidelines.

According to the chapter on exception protocols, there is a study of over 600 instances of deviation from the ODG guidelines finding that 94% of the deviations were medically appropriate. This suggests that deviation is not uncommon and is often the right thing to do.

Now the ODG has given us five things to consider before deviating from the guidelines. When medical care is an exception to the ODG guidelines, the health care provider should document (in your medical records):

  1. the extenuating circumstances that warrant the treatment

  2. co-morbidities (other health factors)

  3. objective signs of functional improvement from the prior treatment provided

  4. measureable goals and progress points expected from additional treatment, and

  5. any additional evidence that supports the request

The most significant factors are co-morbidities and the documented functional improvement of prior treatment. For instance, if the request is for additional physical therapy, then the records should show how the prior therapy helped. There is no need to repeat treatment that didn't result in improving your condition.

Now with some guidance on deviating from the guidelines, maybe a few more injured workers can get the treatment they need.

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