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Definition of Medical Treatment Guidelines

Medical treatment guidelines are a statement or other indication of policy or procedure by which to determine a course of treatment for an injured worker in a workers' compensation claim. In Colorado, medical treatment guidelines are defined as "a system of evaluation and treatment guidelines for high cost or high frequency categories of occupational injury and disease that will assure appropriate medical care at a reasonable cost [Colorado Revised Statutes, Section 8-40-201 13.5 (a)].In New York, the medical treatment guidelines are said to be "evidenced-based,supported by the strongest medical studies when available; and, in the absence of strong medical evidence, they are based on the consensus of experienced medical professionals.

While the purpose of medical treatment guidelines is said to be educational and advisory, in most states where they are used, they are enforceable, and prior authorization is required for any service that exceeds guideline limits. However, in the State of Washington, while doctors are expected to be familiar with the medical treatment guidelines and follow the recommendations, the guidelines are not considered to be hard-and-fast rules. Good medical judgment is supposed to be used by a doctor in determining how to use and interpret the information in the medical treatment guidelines. Critics of the use of medical treatment guidelines say that the usefulness of applying it to an injured worker is limited, and it reduces the autonomy of the doctor-patient relationship by limiting an injured worker's right to choose what is best in their individual circumstances.

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