Utilization and Treatment Guidelines
The Montana Guidelines establish evidence-based utilization and treatment guidelines for primary and secondary medical services for workers' compensation injuries and occupational diseases, as authorized by § 39-71-704, MCA, and incorporated by reference in ARM 24.29.1611.
The purpose of the Guidelines is to ensure injured workers receive prompt and appropriate care, offer injured workers stay-at-work/return-to-work options, guide clinicians in making decisions for specific conditions, and help insurers make reimbursement determinations. The General Guideline Principles at the beginning of each guideline chapter are designed to consistently address the functional improvement goals of an injured worker.
Prior authorization is not required for treatment within the Guidelines except when specifically indicated or for treatments included as “not recommended” in the guidelines. Prior authorization may be obtained in specific cases for treatments outside the guidelines as provided by ARM 24.29.1621. Disputes regarding treatment and prior authorization may be brought to the Department under the Independent Medical Review process, as described in ARM 24.29.1641.
The Guidelines are applicable to all medical services provided on or after July 1, 2011. The Guidelines establish a presumption of compensability for injuries and occupational diseases occurring on or after July 1, 2007. For those occurring on or before June 30, 2007, treatment in accordance with the guidelines constitutes reasonable primary or secondary medical treatment.
Although the primary purpose of the guidelines is advisory and educational, the guidelines are enforceable for payment purposes. The department recognizes that acceptable medical practice may include deviations from these guidelines, as individual cases dictate. Therefore, these guidelines are not relevant as evidence of a provider's legal standard of professional care. Managed Care Organizations and Preferred Provider Organizations are required to follow the Guidelines, but the Guidelines do not alter their payment agreements.