reglab/statecodes huggingface dataset:
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.5.2 - Medical Treatment Utilization Schedule › Section 9792.23.11 - Occupational/Work-Related Asthma Guideline

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The Administrative Director adopts and incorporates by
						reference the Occupational/Work-Related Asthma Guideline (ACOEM June 5, 2020)
						into the MTUS from the ACOEM Practice Guidelines.
1. New
						section filed 1-11-2018; operative 12-1-2017. Submitted to OAL for filing and
						printing only pursuant to Labor Code section
						5307.27(a)
						(Register 2018, No. 2).
2. Amendment of section heading and section
						filed 9-10-2020; operative 9-21-2020. Submitted to OAL for filing and printing
						only pursuant to Labor Code section
						5307.27(a)
						(Register 2020, No. 37).
Note: Authority cited: Sections
						  133,
						  4603.5 and
						  5307.27, Labor
						  Code. Reference: Sections
						  77.5,
						  4600,
						  4604.5 and
						  5307.27, Labor
						  Code.
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.5.2 - Medical Treatment Utilization Schedule › Section 9792.23.12 - Occupational Interstitial Lung Disease Guideline

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The Administrative Director adopts and incorporates by
						reference the Occupational Interstitial Lung Disease Guideline (ACOEM November
						8, 2019) into the MTUS from the ACOEM Practice Guidelines.
1. New
						section filed 1-11-2018; operative 12-1-2017. Submitted to OAL for filing and
						printing only pursuant to Labor Code section
						5307.27(a)
						(Register 2018, No. 2).
2. Amendment filed 9-10-2020; operative
						9-21-2020. Submitted to OAL for filing and printing only pursuant to Labor Code
						section
						5307.27(a)
						(Register 2020, No. 37).
Note: Authority cited: Sections
						  133,
						  4603.5 and
						  5307.27, Labor
						  Code. Reference: Sections
						  77.5,
						  4600,
						  4604.5 and
						  5307.27, Labor
						  Code.
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.5.2 - Medical Treatment Utilization Schedule › Section 9792.24 - Special Topics

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Special topics refer to clinical topic areas where the Administrative Director
					 has determined that the clinical topic sections of the MTUS require further
					 supplementation.
1. New
						section filed 6-18-2009; operative 7-18-2009 (Register 2009, No.
						25).
2. Editorial correction of operative date in HISTORY 1
						(Register 2009, No. 30).
Note: Authority cited: Sections
						  133,
						  4603.5,
						  5307.3 and
						  5307.27, Labor
						  Code. Reference: Sections
						  77.5,
						  4600,
						  4604.5 and
						  5307.27, Labor
						  Code.
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.5.2 - Medical Treatment Utilization Schedule › Section 9792.24.1 - Acupuncture Medical Treatment Guidelines

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Guidance for acupuncture treatment and evaluation are
						contained in the applicable Clinical Topics guidelines, and/or Chronic Pain
						Guideline, and/or Opioid Guideline.
1.
						Renumbering and amendment of former section
						9792.21, subsections
						(a)(2)-(a)(2)(E) to new section
						9792.24.1 filed 6-18-2009;
						operative 7-18-2009 (Register 2009, No. 25).
2. Editorial correction
						of operative date in HISTORY 1 (Register 2009, No. 30).
3. Amendment
						of subsection (d) filed 4-20-2015; operative 4-20-2015 pursuant to Government
						Code section
						11343.4(b)(3)
						(Register 2015, No. 17).
4. Repealer and new section filed
						1-11-2018; operative 12-1-2017. Submitted to OAL for filing and printing only
						pursuant to Labor Code section
						5307.27(a)
						(Register 2018, No. 2).
Note: Authority cited: Sections
						  133,
						  4603.5,
						  5307.3 and
						  5307.27, Labor
						  Code. Reference: Sections
						  77.5,
						  4600,
						  4604.5 and
						  5307.27, Labor
						  Code.
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.5.2 - Medical Treatment Utilization Schedule › Section 9792.24.2 - Chronic Pain Guidelines

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The Administrative Director adopts and incorporates by
						reference the Chronic Pain Guideline (ACOEM May 15, 2017) into the MTUS from
						the ACOEM Practice Guidelines for the treatment and evaluation of patients who
						have chronic pain as defined in section
						9792.20. This guideline addresses a
						general approach to patients with chronic pain and the psychological and
						behavioral aspects of chronic pain. This guideline also addresses a few
						specific chronic pain disorders (i.e., complex regional pain syndrome,
						fibromyalgia, neuropathic pain). Guidance for treatment and evaluation of
						chronic pain disorders not specifically addressed in this guideline are
						contained in the Clinical Topics guidelines and/or Opioid
						Guideline.
1. New
						section filed 6-18-2009; operative 7-18-2009 (Register 2009, No.
						25).
2. Editorial correction of operative date in HISTORY 1
						(Register 2009, No. 30).
3. Amendment filed 7-28-2016; operative
						7-28-2016 pursuant to Government Code section
						11343.4(b)(3)
						(Register 2016, No. 31).
4. Amendment of section heading and
						repealer and new section filed 1-11-2018; operative 12-1-2017. Submitted to OAL
						for filing and printing only pursuant to Labor Code section
						5307.27(a)
						(Register 2018, No. 2).
Note: Authority cited: Sections
						  133,
						  4603.5,
						  5307.3 and
						  5307.27, Labor
						  Code. Reference: Sections
						  77.5,
						  4600,
						  4604.5 and
						  5307.27, Labor
						  Code.
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.5.2 - Medical Treatment Utilization Schedule › Section 9792.24.3 - Postoperative Rehabilitation Guidelines

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Guidance for postoperative rehabilitation treatment and
						evaluation are contained in the Clinical Topics guidelines, and/or Chronic Pain
						Guideline and/or Opioid Guideline. The post-operative rehabilitation treatment
						recommendations apply to visits during the post-operative period only and to
						surgeries as defined in those guidelines. At the conclusion of the
						post-operative period, treatment reverts back to the applicable 24-visit
						limitation for chiropractic, occupational therapy, and physical therapy
						pursuant to Labor Code section
						4604.5(c)(1).
1. New
						section filed 6-18-2009; operative 7-18-2009 (Register 2009, No.
						25).
2. Editorial correction of operative date in HISTORY 1
						(Register 2009, No. 30).
3. Amendment of subsection (d)(1) filed
						4-20-2015; operative 4-20-2015 pursuant to Government Code section
						11343.4(b)(3)
						(Register 2015, No. 17).
4. Amendment of section heading and
						repealer and new section filed 1-11-2018; operative 12-1-2017. Submitted to OAL
						for filing and printing only pursuant to Labor Code section
						5307.27(a)
						(Register 2018, No. 2).
Note: Authority cited: Sections
						  133,
						  4603.5,
						  5307.3 and
						  5307.27, Labor
						  Code. Reference: Sections
						  77.5,
						  4600,
						  4604.5 and
						  5307.27, Labor
						  Code.
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.5.2 - Medical Treatment Utilization Schedule › Section 9792.24.4 - Opioids Guidelines

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 The Administrative Director adopts and incorporates by reference the Opioids
					 Guidelines (ACOEM December 12, 2023) into the MTUS from the ACOEM Practice
					 Guidelines.
(b) The Opioids
					 Guidelines describes the appropriate use of opioid medications as part of an
					 overall multidisciplinary treatment regimen for acute, sub-acute,
					 post-operative, and chronic non-cancer pain. This guideline applies when the
					 use of opioid medications is being considered as part of the treatment
					 regimen.
Note: Authority cited: Sections 133, 4603.5, 5307.3 and
						  5307.27, Labor Code. Reference: Sections 77.5, 4600, 4604.5 and 5307.27, Labor
						  Code.
Note: Authority cited: Sections
						  133,
						  4603.5,
						  5307.3 and
						  5307.27, Labor
						  Code. Reference: Sections
						  77.5,
						  4600,
						  4604.5 and
						  5307.27, Labor
						  Code.
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.5.2 - Medical Treatment Utilization Schedule › Section 9792.24.5 - Traumatic Brain Injury Guideline

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The Administrative Director adopts and incorporates by
						reference the Traumatic Brain Injury Guideline (ACOEM November 15, 2017) into
						the MTUS from the ACOEM Practice Guidelines.
1. New
						section filed 10-30-2018; operative 10-31-2018. Submitted to OAL for filing and
						printing only pursuant to Labor Code section
						5307.27(a)
						(Register 2018, No. 44).
Note: Authority cited: Sections
						  133,
						  4603.5,
						  5307.3 and
						  5307.27, Labor
						  Code. Reference: Sections
						  77.5,
						  4600,
						  4604.5 and
						  5307.27, Labor
						  Code.
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.5.2 - Medical Treatment Utilization Schedule › Section 9792.24.6 - Antiemetics Guideline

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The Administrative Director adopts and incorporates by
						reference the Antiemetics Guideline (ACOEM March 27, 2020) into the MTUS from
						the ACOEM Practice Guidelines.
1. New
						section filed 10-26-2020; operative 10-26-2020. Submitted to OAL for filing and
						printing only pursuant to Labor Code section
						5307.27(a)
						(Register 2020, No. 44).
Note: Authority cited: Sections
						  133,
						  4603.5,
						  5307.3 and
						  5307.27, Labor
						  Code. Reference: Sections
						  77.5,
						  4600,
						  4604.5 and
						  5307.27, Labor
						  Code.
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.5.2 - Medical Treatment Utilization Schedule › Section 9792.24.7 - COVID-19 Guideline

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The Administrative Director adopts and incorporates by
						reference the COVID-19 Guideline (June 28, 2023) into the MTUS from the ACOEM
						Practice Guidelines.
Note: Authority cited: Sections
						  133,
						  4603.5,
						  5307.3 and
						  5307.27, Labor
						  Code. Reference: Sections
						  77.5,
						  4600,
						  4604.5 and
						  5307.27, Labor
						  Code.
Note: Authority cited: Sections
						  133,
						  4603.5,
						  5307.3 and
						  5307.27, Labor
						  Code. Reference: Sections
						  77.5,
						  4600,
						  4604.5 and
						  5307.27, Labor
						  Code.
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.5.2 - Medical Treatment Utilization Schedule › Section 9792.27.1 - Medical Treatment Utilization Schedule (Mtus) Drug Formulary - Definitions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
For purposes of sections
						9792.27.1 through
						9792.27.23, the following
						definitions shall apply:
(a)
					 "Administer" means the direct application of a drug or device to the body of
					 the patient by injection, inhalation, ingestion, or other means.
(b) "Authorization through prospective
					 review" means authorization for proposed treatment obtained through the
					 utilization review process set forth in section
					 9792.6.1 et seq.
(c) "Brand name drug" means a drug that is
					 produced or distributed under an FDA original New Drug Application (NDA) or
					 Biologic License Application (BLA) approved by the FDA. It also includes a drug
					 product marketed by any cross-licensed producers or distributors operating
					 under the same NDA or BLA.
(d)
					 "Combination drug" means a fixed dose combination of two or more active drug
					 ingredients into a single dosage form that is FDA-approved for
					 marketing.
(e) "Compounded drug"
					 means any drug subject to:
(1) Article 4.5
					 (commencing with section
					 1735) or article 7 (commencing with
					 section 1751) of division 17 of title 16 of
					 the California Code of Regulations, or
(2) Other regulation adopted by the State
					 Board of Pharmacy to govern the practice of compounding, or
(3) Federal law governing compounding,
					 including title 21, United State Code, sections
					 353 a, 353a-1,
					 353b.
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.5.2 - Medical Treatment Utilization Schedule › Section 9792.27.2 - Mtus Drug Formulary; Mtus Drug List; Scope of Coverage; Effective Date

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Drugs
					 prescribed or dispensed to treat a work related injury or illness fall within
					 Labor Code section
					 4600 's
					 definition of "medical treatment" and are subject to the relevant provisions of
					 the MTUS, including the MTUS Treatment Guidelines, provisions relating to the
					 presumption of correctness, and the methods for rebutting the presumption and
					 for substantiating medical necessity where the MTUS Treatment Guidelines do not
					 address the condition or injury.
(b) Except for continuing drug treatment
					 subject to section
					 9792.27.3, subdivision (b), a drug
					 dispensed on or after January 1, 2018 for outpatient use shall be subject to
					 the MTUS Drug Formulary, regardless of the date of injury.
(1) A drug is for "outpatient use" if it is
					 dispensed to be taken, applied, or self-administered by the patient at home or
					 outside of a clinical setting, including "take home" drugs dispensed at the
					 time of discharge from a facility. "Home" includes an institutional setting in
					 which the injured worker resides, including but not limited to, an assisted
					 living facility.
(2) The MTUS Drug
					 Formulary does not apply to drugs administered to the patient by a physician.
					 However, the physician administered drug treatment is subject to relevant
					 provisions of the MTUS, including the MTUS Treatment
					 Guidelines.
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.5.2 - Medical Treatment Utilization Schedule › Section 9792.27.3 - Mtus Drug Formulary Transition

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Except as provided in subdivision (b),
					 the MTUS Drug Formulary applies to drugs dispensed on or after January 1, 2018,
					 regardless of the date of injury.
(b)
(1) For
					 injuries occurring prior to January 1, 2018, the MTUS Drug Formulary should be
					 phased in to ensure that injured workers who are receiving ongoing drug
					 treatment are not harmed by an abrupt change to the course of treatment. The
					 physician is responsible for requesting a medically appropriate and safe course
					 of treatment for the injured worker in accordance with the MTUS, which may
					 include use of a Non-Exempt drug or unlisted drug, where that is necessary for
					 the injured worker's condition or necessary for safe weaning, tapering, or
					 transition to a different drug.
(2)
					 If the injured worker with a date of injury prior to January 1, 2018 is
					 receiving a course of treatment that includes a Non-Exempt drug, an unlisted
					 drug, or a compounded drug, the physician shall submit a progress report issued
					 pursuant to section
					 9785 and a Request for
					 Authorization that shall address the injured worker's ongoing drug treatment
					 plan. The report shall either:
(A) Include a
					 treatment plan setting forth a medically appropriate weaning, tapering, or
					 transitioning of the worker to a drug pursuant to the MTUS, or
(B) Provide supporting documentation, as
					 appropriate, to substantiate the medical necessity of, and to obtain
					 authorization for, the Non-Exempt drug, unlisted drug, or compounded drug,
					 pursuant to the MTUS (via guidelines, Medical Evidence Search Sequence, and/or
					 Methodology for Evaluating Medical Evidence.)
(3) The progress report, including the
					 treatment plan and Request for Authorization provided under this subdivision,
					 shall be submitted at the time the next progress report is due under section
					 9785, subdivision (f)(8), however,
					 if that is not feasible, no later than April 1, 2018.
(4) Previously approved drug treatment shall
					 not be terminated or denied except as may be allowed by the MTUS and in
					 accordance with applicable utilization review and independent medical review
					 regulations.
(5) The claims
					 administrator shall process the progress report, treatment plan and Request for
					 Authorization in accordance with the standard procedures and timeframes set
					 forth in section
					 9792.6.1 et
					 seq.
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.5.2 - Medical Treatment Utilization Schedule › Section 9792.27.4 - Mtus Drug Formulary - Pharmacy Networks; Pharmacy Benefit Manager Contracts

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Where an employer or insurer contracts pursuant to Labor
						Code section
						4600.2 with a
						pharmacy, a pharmacy benefit manager, or pharmacy network for the provision of
						drugs for the treatment of injured workers, the drugs available to the injured
						worker must be consistent with the MTUS Treatment Guidelines and MTUS Drug
						Formulary for the condition or injury being treated, and may not be restricted
						pursuant to the contract.
1. New
						section filed 12-7-2017; operative 1-1-2018 pursuant to Government Code section
						11343.4(b)(3)
						(Register 2017, No. 49).
Note: Authority cited: Sections
						  133,
						  4603.5,
						  5307.3 and
						  5307.27, Labor
						  Code. Reference: Sections
						  4600,
						  4600.2,
						  4604.5 and
						  5307.27, Labor
						  Code.
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.5.2 - Medical Treatment Utilization Schedule › Section 9792.27.5 - Mtus Drug Formulary - off-Label Use

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Off-label use of a drug shall be in
					 accordance with the MTUS Treatment Guidelines and rules and the MTUS Drug
					 Formulary.
(b) Authorization
					 through prospective review is not required to dispense an Exempt drug for an
					 off-label use if the MTUS Treatment Guideline recommends the off-label use of
					 the drug to treat the condition.
(c) Authorization through prospective review
					 is required prior to dispensing the following drugs for an off-label use:
(1) Non-Exempt drug, or
(2) Unlisted drug, or
(3) Exempt drug lacking recommendation in the
					 MTUS Treatment Guideline for the intended off-label use.
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.5.2 - Medical Treatment Utilization Schedule › Section 9792.27.6 - Mtus Drug Formulary - Access to Drugs Not Listed as an Exempt Drug on the Mtus Drug List

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Drug
					 treatment that is in conformity with the MTUS Treatment Guidelines is presumed
					 correct on the issue of extent and scope of medical treatment pursuant to
					 section 9792.21, subdivision (c), and Labor
					 Code section
					 4604.5.
					 Although the MTUS Drug List identifies Exempt drugs that do not require
					 prospective review when dispensed in accordance with the MTUS Treatment
					 Guidelines, other medically necessary drugs are available to the injured worker
					 when authorized through prospective review.
(b) Any medically necessary FDA-approved
					 drug, or nonprescription drug that is marketed pursuant to an FDA OTC
					 Monograph, may be authorized through prospective review and dispensed to an
					 injured worker if it is shown in accordance with the MTUS regulations that the
					 drug is required to cure or relieve the injured worker from the effects of the
					 injury. Determination of the medical necessity of treatment based on
					 recommendations found outside of the MTUS Treatment Guidelines is governed by
					 section 9792.21 subdivision (d) (condition
					 not addressed by MTUS or seeking to rebut the MTUS), section
					 9792.21.1 (medical evidence search
					 sequence), section
					 9792.25 (quality and strength of
					 evidence definitions) and section
					 9792.25.1 (MTUS methodology for
					 evaluating medical evidence).
1. New
						section filed 12-7-2017; operative 1-1-2018 pursuant to Government Code section
						11343.4(b)(3)
						(Register 2017, No. 49).
Note: Authority cited: Sections
						  133,
						  4603.5,
						  5307.3 and
						  5307.27, Labor
						  Code. Reference: Sections
						  4600,
						  4604.5 and
						  5307.27, Labor
						  Code.
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.5.2 - Medical Treatment Utilization Schedule › Section 9792.27.7 - Mtus Drug Formulary - Brand Name Drugs; Generic Drugs

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
If a physician prescribes a brand name drug when a less
						costly therapeutically equivalent generic drug exists, and writes "Do Not
						Substitute" or "Dispense as Written" on the prescription in conformity with
						Business and Professions Code section
						4073,
						the physician must document the medical necessity for prescribing the brand
						name drug in the patient's medical chart and in the Doctor's First Report of
						Injury (Form 5021) or Progress Report (PR-2.) The documentation must include
						the patient-specific factors that support the physician's determination that
						the brand name drug is medically necessary. The physician must submit a Request
						for Authorization and obtain authorization through prospective review before
						the brand name drug is dispensed.
1. New
						section filed 12-7-2017; operative 1-1-2018 pursuant to Government Code section
						11343.4(b)(3)
						(Register 2017, No. 49).
Note: Authority cited: Sections
						  133,
						  4603.5,
						  5307.3 and
						  5307.27, Labor
						  Code. Reference: Sections
						  4600,
						  4604.5 and
						  5307.27, Labor
						  Code.
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.5.2 - Medical Treatment Utilization Schedule › Section 9792.27.8 - Physician-Dispensed Drugs

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Drugs dispensed by a physician must be authorized through prospective review
					 prior to being dispensed, except as provided in subdivision (b), section
					 9792.27.12 ("Special Fill"), and
					 section 9792.27.13 ("Perioperative
					 Fill").
(b) A physician may
					 dispense up to a seven-day supply of one or more drugs that are designated as
					 "Exempt" in the MTUS Drug List without obtaining authorization through
					 prospective review, if the drug treatment is in accordance with the MTUS
					 Treatment Guidelines and the up-to-seven-day supply is dispensed at the time of
					 an initial visit that occurs within 7 days of the date of injury.
(c) Nothing in this Article shall invalidate
					 a provision in a Medical Provider Network agreement which restricts physician
					 dispensing by medical providers within the network.
(d) Nothing in this Article shall permit
					 physician dispensing where otherwise prohibited by a pharmacy benefit contract
					 pursuant to subdivision (a) of Labor Code section
					 4600.2.
1. New
						section filed 12-7-2017; operative 1-1-2018 pursuant to Government Code section
						11343.4(b)(3)
						(Register 2017, No. 49).
Note: Authority cited: Sections
						  133,
						  4603.5,
						  5307.3 and
						  5307.27, Labor
						  Code. Reference: Sections
						  4600,
						  4604.5 and
						  5307.27, Labor
						  Code.
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.5.2 - Medical Treatment Utilization Schedule › Section 9792.27.9 - Compounded Drugs

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Compounded drugs must be authorized through prospective review prior to being
					 dispensed. When it is necessary for medical reasons to prescribe or dispense a
					 compounded drug instead of an FDA-approved drug or over-the-counter drug that
					 complies with an OTC Monograph, the physician must document the medical
					 necessity in the patient's medical chart, and in the Doctor's First Report of
					 Injury (Form 5021) or Progress Report (PR-2) and must submit a Request for
					 Authorization. The documentation must include the patient-specific factors that
					 support the physician's determination that a compounded drug is medically
					 necessary.
(b) Nothing in this
					 Article shall invalidate a provision in a Medical Provider Network agreement
					 which restricts physician dispensing of compounded drugs by medical providers
					 within the network.
(c) Nothing in
					 this Article shall permit physician dispensing of compounded drugs where
					 otherwise prohibited by a pharmacy benefit contract pursuant to subdivision (a)
					 of Labor Code section
					 4600.2.
1. New
						section filed 12-7-2017; operative 1-1-2018 pursuant to Government Code section
						11343.4(b)(3)
						(Register 2017, No. 49).
Note: Authority cited: Sections
						  133,
						  4603.5,
						  5307.3 and
						  5307.27, Labor
						  Code. Reference: Sections
						  4600,
						  4604.5 and
						  5307.27, Labor
						  Code.
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.5.2 - Medical Treatment Utilization Schedule › Section 9792.27.10 - Mtus Drug List; Exempt Drugs, Non-Exempt Drugs, Unlisted Drugs, Prospective Review

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 The MTUS Drug List is set forth by active drug ingredient(s).
(b) A drug that is identified as "Exempt" may
					 be dispensed to the injured worker without obtaining authorization through
					 prospective review if the drug treatment is in accordance with the MTUS
					 Treatment Guidelines, except:
(1) Brand name
					 drugs are subject to section
					 9792.27.7;
(2) Physician-dispensed drugs are subject to
					 section 9792.27.8.
(3) Compounded drugs are subject to section
					 9792.27.9 even if one or more of
					 the ingredients is listed as "Exempt" on the MTUS Drug
					 List.
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.5.2 - Medical Treatment Utilization Schedule › Section 9792.27.11 - Waiver of Prospective Review

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Nothing in the MTUS Drug Formulary shall prohibit waiver
						of the prospective review requirement for a Non-Exempt or unlisted drug if the
						drug falls within a utilization review plan's provision of prior authorization
						without necessity of a request for authorization, where that provision is
						adopted pursuant to section
						9792.7, subdivision
						(a)(5).
1. New
						section filed 12-7-2017; operative 1-1-2018 pursuant to Government Code section
						11343.4(b)(3)
						(Register 2017, No. 49).
Note: Authority cited: Sections
						  133,
						  4603.5,
						  5307.3 and
						  5307.27, Labor
						  Code. Reference: Sections
						  4600,
						  4604.5 and
						  5307.27, Labor
						  Code.
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.5.2 - Medical Treatment Utilization Schedule › Section 9792.27.12 - Mtus Drug List - Special Fill

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The MTUS Drug List identifies drugs that
					 are subject to the Special Fill policy. Under this policy, a drug that usually
					 requires prospective review because it is "Non-Exempt" will be allowed without
					 prospective review as specified in subdivision (b).
(b) The drug identified as a Special Fill
					 drug may be dispensed to the injured worker without seeking prospective review
					 if all of the following conditions are met:
(1) The drug is prescribed at the single
					 initial treatment visit following a workplace injury, provided that the initial
					 visit is within 7 days of the date of injury; and
(2) The prescription is for a supply of the
					 drug not to exceed the limit set forth in the MTUS Drug List; and
(3) The prescription for the Special
					 Fill-eligible drug is for:
(A) An FDA-approved
					 generic drug or single source brand name drug, or,
(B) A brand name drug where the physician
					 documents and substantiates the medical need for the brand name drug rather
					 than the FDA-approved generic drug, and
(4) The drug is prescribed in accordance with
					 the MTUS Treatment Guidelines.
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.5.2 - Medical Treatment Utilization Schedule › Section 9792.27.13 - Mtus Drug List - Perioperative Fill

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The MTUS Drug List identifies drugs that
					 are subject to the Perioperative Fill policy. Under this policy, the Non-Exempt
					 drug identified as a Perioperative Fill drug may be dispensed to the injured
					 worker without seeking prospective review if all of the following conditions
					 are met:
(1) The drug is prescribed during
					 the perioperative period; and
(2)
					 The prescription is for a supply of the drug not to exceed the limit set forth
					 in the MTUS Drug List; and
(3) The
					 prescription for the Perioperative Fill -- eligible drug is for:
(A) An FDA-approved generic drug or single
					 source brand name drug, or,
(B) A
					 brand name drug where the physician documents and substantiates the medical
					 need for the brand name drug rather than the FDA-approved generic drug,
					 and
(4) The drug is
					 prescribed in accordance with the MTUS Treatment
					 Guidelines.
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.5.2 - Medical Treatment Utilization Schedule › Section 9792.27.14 - Treatment Provided Under Applicable Health and Safety Regulations

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The MTUS Drug Formulary and associated regulations do not
						relieve an employer of any responsibilities pursuant to applicable health and
						safety regulations such as the requirements of the California occupational
						Bloodborne Pathogens standard at title 8, California Code of Regulations,
						section 5193, including the responsibility
						to provide urgent post-exposure prophylaxis as needed to protect the health of
						the employee.
1. New
						section filed 12-7-2017; operative 1-1-2018 pursuant to Government Code section
						11343.4(b)(3)
						(Register 2017, No. 49).
Note: Authority cited: Sections
						  133,
						  4603.5,
						  5307.3 and
						  5307.27, Labor
						  Code. Reference: Sections
						  4600,
						  4604.5 and
						  5307.27, Labor
						  Code.
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.5.2 - Medical Treatment Utilization Schedule › Section 9792.27.15 - Mtus Drug List

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
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1. New
						section filed 12-7-2017; operative 1-1-2018 pursuant to Government Code section
						11343.4(b)(3)
						(Register 2017, No. 49).
Note: Authority cited: Sections
						  133,
						  4603.5,
						  5307.3 and
						  5307.27, Labor
						  Code. Reference: Sections
						  4600,
						  4604.5 and
						  5307.27, Labor
						  Code.
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.5.2 - Medical Treatment Utilization Schedule › Section 9792.27.16 - National Drug Codes, Unique Pharmaceutical Identifier - Mtus Drug List

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The
					 Administrative Director may maintain and post on the DWC website a listing by
					 National Drug Code, RxCUI (clinical drug concept unique identifier maintained
					 by the National Library of Medicine), or other unique pharmaceutical
					 identifier, of drug products that are embodied in the MTUS Drug List. If
					 posted, the listing will be regularly updated to account for revisions to the
					 MTUS Drug List and for changes in drug products that are marketed for
					 outpatient use.
(b) For each active
					 ingredient on the MTUS Drug List, the product listing shall include brand name
					 and therapeutically equivalent generic versions of outpatient prescription
					 drugs and non-prescription drug products. The listing shall include only drug
					 products that can be self-administered by the patient. Injectable drug products
					 must be packaged and identified for patient self-administration.
(c) The listing shall include combination
					 drugs with multiple active ingredients only if the combination of active
					 ingredients is listed on the MTUS Drug List.
(d) The listing may include, but is not
					 limited to, the following data elements:
(1)
					 National Drug Code, RxCUI, or other pharmaceutical identifier;
(2) Drug ingredient(s);
(3) Therapeutic class;
(4) Strength;
(5) Dosage form;
(6) Exempt or Non-Exempt status, as
					 applicable;
(7) Any applicable
					 Special Fill or Perioperative Fill policies.
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.5.2 - Medical Treatment Utilization Schedule › Section 9792.27.17 - Formulary - Dispute Resolution

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Medical Necessity Disputes.
Disputes over the medical necessity of pharmaceutical
						treatment covered by the MTUS Drug Formulary are governed by the utilization
						review and independent medical review provisions of Labor Code sections
						4610,
						4610.5, and
						regulations at section
						9792.6.1 et seq, and section
						9792.10.1 et seq.
(b) Formulary Rule Medical Treatment Disputes
					 Other than Medical Necessity Disputes.
Disputes over failure to follow formulary rules, other
						than medical necessity disputes covered by subdivision (a), shall be resolved
						through the procedure for non-IMR/IBR disputes set forth in WCAB rules, title
						8, California Code of Regulations, section
						10451.2, Determination of Medical
						Treatment Disputes.
1. New
						section filed 12-7-2017; operative 1-1-2018 pursuant to Government Code section
						11343.4(b)(3)
						(Register 2017, No. 49).
Note: Authority cited: Sections
						  133,
						  4603.5,
						  5307.3,
						  5307.1 and
						  5307.27, Labor
						  Code. Reference: Sections
						  4600,
						  4604.5,
						  5307.1,
						  5307.27 and
						  5307.29, Labor
						  Code.
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.5.2 - Medical Treatment Utilization Schedule › Section 9792.27.18 - Pharmacy and Therapeutics Committee - Composition; Application for Appointment; Term of Service

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 The Administrative Director shall create an independent Pharmacy and
					 Therapeutics Committee (P&T Committee) to review and consult with the
					 Administrative Director on available evidence of the relative safety, efficacy,
					 and effectiveness of drugs within a class of drugs, for purposes of updating
					 the MTUS Drug List.
(b) The P&T
					 Committee shall consist of the Executive Medical Director, and six members
					 appointed by the Administrative Director.
(1)
					 The Executive Medical Director, or his or her designee, shall serve as
					 chairperson of the P&T Committee. If the Executive Medical Director
					 position becomes vacant, the Administrative Director shall appoint a competent
					 person to temporarily assume the authority and duties of the Executive Medical
					 Director on the P&T Committee, until such time that the Executive Medical
					 Director position is filled.
(2)
					 The Administrative Director shall appoint 3 pharmacists and 3 physicians
					 (medical doctors or doctors of osteopathy) to serve on the P&T Committee.
					 At least one of the physicians appointed shall be actively engaged in the
					 treatment of injured workers. At least one of the pharmacists appointed shall
					 be an actively practicing pharmacist.
(3) The members of the P&T Committee
					 shall be appointed to serve a two-year term, but shall remain in the position
					 until a successor is appointed. A member may apply to be reappointed when his
					 or her two-year term ends. The Administrative Director may cancel the
					 appointment of a committee member if a substantial conflict of interest arises,
					 or for other reason constituting good cause.
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.5.2 - Medical Treatment Utilization Schedule › Section 9792.27.19 - Pharmacy and Therapeutics Committee - Application for Appointment to Committee Form

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
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1. New
						section filed 12-7-2017; operative 1-1-2018 pursuant to Government Code section
						11343.4(b)(3)
						(Register 2017, No. 49).
Note: Authority cited: Sections
						  133,
						  4603.5,
						  5307.3 and
						  5307.27, Labor
						  Code. Reference: Sections
						  4600,
						  4604.5,
						  5307.27 and
						  5307.29, Labor
						  Code.
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.5.2 - Medical Treatment Utilization Schedule › Section 9792.27.21 - Pharmacy and Therapeutics Committee - Conflict of Interest Disclosure Form

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
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						here to view image
1. New
						section filed 12-7-2017; operative 1-1-2018 pursuant to Government Code section
						11343.4(b)(3)
						(Register 2017, No. 49).
Note: Authority cited: Sections
						  133,
						  4603.5,
						  5307.3 and
						  5307.27, Labor
						  Code. Reference: Sections
						  4600,
						  4604.5,
						  5307.27 and
						  5307.29, Labor
						  Code.
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.5.2 - Medical Treatment Utilization Schedule › Section 9792.27.22 - Pharmacy and Therapeutics Committee - Meetings

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The P&T Committee shall meet when
					 deemed necessary by the Executive Medical Director, but no less frequently than
					 quarterly.
(b) P&T Committee
					 meetings shall be conducted in accordance with the Bagley-Keene Open Meeting
					 Act, California Government Code sections
					 11120
					 through
					 11132.
(c) Notice of the regularly scheduled
					 meetings shall be given at least ten days in advance of the meeting as follows:
(1) To persons who have requested notice of
					 the meetings;
(2) To persons on the
					 Administrative Director's mailing list; and
(3) By posting notice on the division's
					 website.
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.5.2 - Medical Treatment Utilization Schedule › Section 9792.27.23 - Mtus Drug List Updates

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The Administrative Director shall consult
					 with the P&T Committee as needed on updates to the MTUS Drug List, which
					 may be adopted by the Administrative Director on a quarterly or more frequent
					 basis in order to allow provision for all appropriate medications.
(b) The P&T Committee is responsible for
					 reviewing and consulting with the Administrative Director on available evidence
					 of the relative safety, efficacy, and effectiveness of drugs within a class of
					 drugs. In carrying out these duties the P&T Committee may provide
					 consultation on a variety of relevant issues, including but not limited to the
					 following:
(1) Recommendations on prospective
					 review requirements for drugs;
(2)
					 Recommendations on Special Fill and Perioperative Fill designation and
					 policies;
(3) Review of drug
					 treatment changes adopted into the MTUS Treatment Guidelines to identify needed
					 additions or deletions of drugs from the MTUS Drug List;
(4) Recommendations on establishing a
					 therapeutic interchange program in order to promote safe and appropriate cost
					 effective care.
California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.6 - Medical-Legal Expenses and Comprehensive Medical-Legal Evaluations › Section 9793 - Definitions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
As used in this article:
(a) "Claim" means a claim for compensation as
					 evidenced by either the filing of a claim form pursuant to Section
					 5401 of the
					 Labor Code or notice or knowledge of an injury under Section
					 5400 or
					 5402 of the
					 Labor Code.
(b) "Contested claim"
					 means any of the following:
(1) Where the
					 claims administrator has rejected liability for a claimed benefit.
(2) Where the claims administrator has failed
					 to accept liability for a claim and the claim has become presumptively
					 compensable under Section
					 5402 of the
					 Labor Code.
(3) Where the claims
					 administrator has failed to respond to a demand for the payment of compensation
					 after the expiration of any time period fixed by statute for the payment of
					 indemnity benefits, including where the claims administrator has failed to
					 either commence the payment of temporary disability indemnity or issue a notice
					 of delay within 14 days after knowledge of an employee's injury and disability
					 as provided in Section
					 4650 of the
					 Labor Code.
(4) Where the claims
					 administrator has accepted liability for a claim and a disputed medical fact
					 exists.