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 9792.25.1 - Mtus Methodology for Evaluating Medical Evidence

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) When competing recommendations are cited
					 to guide medical care, Utilization Review and Independent Medical Review
					 physicians shall apply the MTUS Methodology for Evaluating Medical Evidence to
					 evaluate the quality and strength of evidence used to support the
					 recommendations that are at variance with one another. The MTUS Methodology for
					 Evaluating Medical Evidence provides a process to evaluate studies, not
					 guidelines. Therefore, the reviewing physician shall evaluate the underlying
					 study or studies used to support a recommendation found in a guideline. Medical
					 care shall be in accordance with the recommendation supported by the best
					 available evidence. The MTUS Methodology for Evaluating Medical Evidence shall
					 be applied as follows:
(1) The reviewing
					 physician shall determine if different guidelines or studies were cited to
					 guide the injured worker's medical care by the treating physician, the
					 Utilization Review physician and/or the Independent Medical Review physician
					 that contain recommendations that are at variance with one another.
(2) If different guidelines or studies were
					 cited to guide the injured worker's medical care containing recommendations
					 that are at variance with one another, the reviewing physician shall evaluate
					 the quality of evidence by determining if the studies used to support the
					 recommendations are applicable to the injured worker and his or her medical
					 condition or injury. Applicability refers to the extent to which the individual
					 patients, subjects, settings, interventions, and outcome measures of studies
					 used to support a recommendation are similar to the worker and his or her
					 medical condition or injury. A recommendation supported by inapplicable studies
					 should not be used as the source to support, deny, delay or modify an RFA.
					 Reviewing physicians shall provide an explanation of their rationale in the
					 Utilization Review or Independent Medical Review decision if they conclude a
					 recommendation is supported by studies inapplicable to the worker and his or
					 her medical condition or injury.
(A) The
					 evaluation of medical evidence can end after this step if a citation to a
					 guideline or a study contains a recommendation supported by inapplicable
					 studies and the other citation contains a recommendation that is supported by
					 studies applicable to the injured worker's medical condition or
					 injury.
(3) If the
					 guidelines or studies cited contain recommendations supported by studies
					 applicable to the worker and his or her medical condition or injury, then the
					 reviewing physician shall continue to evaluate the quality of evidence by
					 determining what factors, if any, bias may have had in the studies used to
					 support the recommendations. Factors to consider include, but are not limited
					 to, vested interests such as financial interests, academic interests, industry
					 influence, and the methodological safeguards to protect against biases related
					 to the generation of the randomization sequence, concealment of allocation,
					 blinding, selective outcome reporting, early stopping, intention to treat, and
					 confounding bias. A recommendation supported by studies determined to be of
					 poor quality due to the presence of bias should not be used as the source to
					 support, deny, delay or modify an RFA. Reviewing physicians shall provide an
					 explanation of their rationale in the Utilization Review or Independent Medical
					 Review decision if they conclude a recommendation is supported by studies
					 determined to be of poor quality due to the presence of bias.
(A) The evaluation of medical evidence can
					 end after this step if a citation to a guideline or a study contains a
					 recommendation supported by studies determined to be of poor quality due to the
					 presence of bias and the other citation contains a recommendation that is
					 supported by studies determined to be of good quality due to the absence of
					 bias.
(4) If the
					 guidelines or studies cited contain recommendations supported by studies
					 applicable to the worker and his or her medical condition or injury and if the
					 recommendations are supported by studies that are determined to be of good
					 quality due to the absence of bias, then the reviewing physician shall
					 determine the strength of evidence used to support the differing
					 recommendations by applying the Hierarchy of Evidence for Different Clinical
					 Questions set forth in 9792.25.1(b). To apply the Hierarchy of Evidence for
					 Different Clinical Questions, the following steps shall be taken:
(A) Determine the design of the study used to
					 support the recommendation. Study designs are categorized as one of the
					 following categories:
1. Systematic Review of:
(aa) Randomized Controlled Trials
(bb) Prospective or Cohort
					 Studies
2. Randomized
					 Controlled Trials
3. Observational
					 studies:
(aa) Prospective study or Cohort
					 Study
(bb) Cross-sectional
					 study
(cc) Case-control
					 study
(dd) Case-series
(ee) Uncontrolled or observational
					 study
(ff) Case
					 report
4. Published
					 expert opinion
(B)
					 Determine which of the four clinical questions in the MTUS Hierarchy of
					 Evidence for Different Clinical Questions as set forth in Section
					 9792.25.2(b) the
					 study is answering and then apply the corresponding hierarchy(ies) of evidence.
					 The sequence to be followed for each of the four clinical questions is as
					 follows:
1. If the original study answers the
					 question "How useful is Treatment X in treating patients with Disease Y?" then
					 the hierarchy of evidence set forth under Treatment Benefits shall
					 apply.
2. If the original study
					 answers the question "How useful is Test X in diagnosing patients with Disease
					 Y?" then the hierarchy of evidence set forth under Diagnostic Test shall
					 apply.
3. If the original study
					 answers the question "What will happen to a patient with Disease Y if nothing
					 is done?" then the hierarchy of evidence set forth under Prognosis shall
					 apply.
4. If the original study
					 answers the question "What are the harms of intervention (treatment or
					 diagnostic test) X in patients with Disease Y?" then the hierarchy of evidence
					 set forth under Treatment Harms shall apply.
(C) In each Clinical Question category, the
					 levels of evidence are listed from highest to lowest, as defined by the
					 principles of Evidence-Based Medicine. Levels of evidence shall be applied in
					 the order listed. Recommendation for or against medical treatment based on a
					 lower level of evidence shall be permitted only if every higher ranked level of
					 evidence is inapplicable to the employee's medical condition.
1. The level of evidence for each published
					 study (e.g. 1a, 1b, 2, etc.) shall be documented and included with the citation
					 in the Utilization Review or Independent Medical Review decisions.
2. When relying on lower levels of evidence,
					 a written statement shall be provided that states higher levels of evidence are
					 absent.