The Legal Standard: "Reasonably Required to Cure or Relieve"
Labor Code §4600 requires employers to provide "medical, surgical, chiropractic, acupuncture, and hospital treatment...as is reasonably required to cure or relieve the injured worker from the effects of the injury."
What "Reasonably Required" Means:
Treatment must be medically necessary (not just desired), related to the work injury (not pre-existing conditions unless work aggravated them), and based on accepted medical practice (not experimental). Your treating doctor determines medical necessity—not the insurance company.
In practice: If your treating physician says you need surgery, physical therapy, or pain management, insurance must pay for it unless they can prove through medical evidence it's not necessary.
Covered Medical Services (Detailed Breakdown)
Doctor Visits & Specialist Consultations
Covered:
- • Primary treating physician (PTP) visits – no limit
- • Specialist referrals (orthopedic, neurologist, pain management, etc.)
- • Second opinions (if requested by treating doctor)
- • Qualified Medical Evaluator (QME) examinations
- • Emergency room visits for work injury complications
You don't pay copays or deductibles. All doctor visits related to the work injury are 100% covered.
Surgery & Hospital Treatment
Covered:
- • All surgical procedures to repair injury (spinal fusion, joint replacement, rotator cuff repair, etc.)
- • Hospital stays and facility fees
- • Anesthesia
- • Post-operative care and follow-ups
- • Revision surgeries if first surgery fails or complications arise
Important: Surgery requires pre-authorization except in emergencies. Insurance has 5 business days to approve/deny. Denials can be appealed through IMR.
Physical Therapy & Rehabilitation
Covered:
- • Physical therapy (PT) – typically 12-24 sessions initially, more if needed
- • Occupational therapy (OT) for functional restoration
- • Work hardening/conditioning programs
- • Aquatic therapy
- • Therapeutic exercises and stretching
Insurance often limits PT to 24 visits unless doctor justifies medical need for additional sessions.
Chiropractic Care
Covered:
- • Spinal manipulation and adjustments
- • Chiropractic examinations and evaluations
- • Modalities (heat, ice, electrical stimulation)
Limitations: California presumes 24 chiropractic visits in the first year are reasonable. Additional visits require utilization review authorization. You must see chiropractors within the employer's Medical Provider Network (MPN) if applicable.
Prescription Medications
Covered:
- • Pain medications (NSAIDs, opioids if medically necessary)
- • Anti-inflammatory drugs
- • Muscle relaxants
- • Antidepressants for pain management
- • Topical medications and creams
- • Nerve pain medications (Gabapentin, Lyrica)
Process: Doctor writes prescription → Insurance pharmacy benefit manager fills it → You receive medication at no cost (some pharmacies require upfront payment then reimbursement).
Insurance may require generic equivalents or step therapy (try cheaper drugs first before expensive ones).
Diagnostic Testing
Covered:
- • MRI and CT scans
- • X-rays
- • EMG/NCV (nerve conduction studies)
- • Blood tests and lab work
- • Bone density scans
- • Psychological evaluations and testing
Authorization: Advanced imaging (MRI, CT) often requires pre-authorization. X-rays typically don't.
Pain Management
Covered:
- • Epidural steroid injections
- • Facet joint injections
- • Nerve blocks
- • Trigger point injections
- • Radiofrequency ablation
- • Pain management consultations
- • TENS units
All injection-based pain management requires pre-authorization and is subject to utilization review.
Medical Equipment & Supplies
Covered:
- • Crutches, walkers, wheelchairs
- • Back braces, knee braces, wrist splints
- • CPAP machines (if sleep apnea caused by injury)
- • Home modifications (wheelchair ramps for severe disabilities)
- • Prosthetics and orthotics
- • Ergonomic office equipment (if prescribed)
Home Health Care
Covered (for severe injuries):
- • In-home nursing care
- • Physical therapy at home
- • Attendant care for daily living activities
- • Home health aide services
Requirement: Doctor must certify you need home care and can't travel to appointments. Typically only for catastrophic injuries (severe TBI, paralysis, amputations).
Psychological Treatment
Covered (if work-related):
- • Psychotherapy for work-related PTSD, anxiety, depression
- • Psychiatric medication management
- • Psychological testing and evaluations
- • Treatment for pain-related depression
Important limitation: Psychological treatment must be related to the physical injury or a compensable psychiatric injury. General mental health treatment unrelated to work isn't covered.
Transportation & Mileage Reimbursement
Covered:
- • Mileage reimbursement at IRS rate (currently ~65¢/mile) for medical appointments
- • Parking fees
- • Tolls
- • Public transportation costs
- • Ambulance services if medically necessary
Keep detailed mileage logs. Submit reimbursement requests with appointment dates and odometer readings.
Treatment NOT Covered
What Workers' Comp Does NOT Cover:
- ✗ Medical marijuana – Not reimbursable under California workers' comp despite legalization
- ✗ Experimental treatments – Must be proven effective and accepted medical practice
- ✗ Cosmetic surgery – Unless disfigurement directly caused by work injury
- ✗ Treatment for pre-existing conditions – Unless work injury aggravated/worsened them
- ✗ Over-the-counter medications – Unless prescribed by treating doctor
- ✗ Treatment from non-authorized providers – Must use MPN doctors if employer has MPN
The Authorization Process: How to Get Treatment Approved
Treatment Authorization Timeline:
Treating Doctor Recommends Treatment
Doctor determines you need surgery, physical therapy, injections, etc. Documents medical necessity in chart notes.
Doctor Submits Request for Authorization (RFA)
Formal request sent to insurance company with medical justification. Insurance must respond within specific timeframes.
Insurance Reviews (Utilization Review)
Expedited: 72 hours for urgent care (immediate health threat).
Standard: 5 business days for non-urgent treatment.
If Approved: Treatment Proceeds
Insurance authorizes treatment. Doctor schedules procedure. Insurance pays provider directly.
If Denied: Appeal Through IMR
File Independent Medical Review within 30 days. Independent doctor reviews case and makes binding decision (usually within 30 days).
Utilization Review (UR): How Insurance Denies Treatment
Utilization Review, established under Labor Code §4610, is the insurance company's process for evaluating whether requested treatment is "medically necessary." A doctor hired by insurance reviews your treating doctor's request and can deny it.
Common UR Denial Reasons:
- • "Treatment is not medically necessary" (UR doctor disagrees with treating doctor)
- • "Try conservative treatment first" (physical therapy before surgery)
- • "Not within treatment guidelines" (Official Medical Treatment Utilization Schedule)
- • "Pre-existing condition" (claiming injury existed before work)
- • "Not related to work injury" (treating non-industrial body parts)
UR Doctors Are Biased
Reality check: UR doctors are paid by insurance companies to deny treatment. They never examine you, only review paper records. They deny 40-60% of requests. Don't accept UR denials as final—appeal through IMR.
Independent Medical Review (IMR): Appealing Denials
When insurance denies treatment through UR, you have 30 days to file for Independent Medical Review. IMR is your best weapon against unfair denials.
How IMR Works:
- 1. File IMR application within 30 days of UR denial (forms available from DWC website)
- 2. Submit to Division of Workers' Comp along with denial letter and supporting medical records
- 3. Independent doctor reviews case – Not paid by insurance, truly neutral physician
- 4. IMR decision issued within 30 days (expedited in 3 days for urgent cases)
- 5. Decision is binding – If IMR approves treatment, insurance MUST authorize it within 5 days
IMR Success Rate: Workers win approximately 60% of IMR appeals. The independent doctor is far more objective than insurance UR doctors. Always appeal UR denials through IMR.
Choosing Your Doctor: MPN Rules
Your choice of doctor depends on whether your employer has a Medical Provider Network (MPN):
If Employer Has MPN:
- • Must choose from MPN list initially (at least 3 doctors per specialty within 30 miles)
- • Can change doctors once within MPN after 30 days
- • Can request second opinion from another MPN doctor
- • Can go outside MPN if no specialist in your area or specific medical need
If No MPN (Or If You Pre-Designated):
- • Pre-designated personal physician – Can use your own doctor if you notified employer in writing before injury
- • Choose any treating doctor after 30 days
- • More flexibility in selecting specialists and changing doctors
What If Insurance Doesn't Pay Medical Bills?
Sometimes insurance refuses to pay providers, leaving you with unexpected medical bills. Here's what to do:
Steps to Resolve Unpaid Medical Bills:
Don't Pay the Bill
You're not personally liable for work injury medical bills. Tell provider it's a workers' comp case.
Contact Insurance Adjuster
Inform adjuster of unpaid bill. Request they pay provider immediately.
Provider Files Lien
Medical provider can file lien against your workers' comp case. Lien gets paid from settlement.
Attorney Negotiates
Your lawyer can negotiate lien reductions and force insurance to pay reasonable medical bills.
Important: Never pay work injury medical bills out of pocket. If you do, insurance will refuse to reimburse you. Let your attorney handle billing disputes.
Future Medical Care After Settlement
Your settlement type determines future medical coverage:
Compromise & Release (C&R) Settlement:
Lump sum settlement that closes medical treatment. You receive money for estimated future medical costs, but insurance no longer pays for treatment. You use settlement funds to pay for future care yourself.
Good if: You want full control and lump sum payment. Bad if: You need expensive ongoing treatment (insurance won't pay anymore).
Stipulated Award (Stips):
Keeps medical treatment open. You receive permanent disability in biweekly payments, but insurance continues covering future medical treatment related to the injury.
Good if: You need ongoing expensive care (future surgeries, pain management). Bad if: You want lump sum and no ongoing insurance company control.
When to Get a Lawyer for Medical Treatment Issues
Contact a California workers' comp attorney if:
- • Insurance denied recommended surgery or treatment (UR denial)
- • You need to appeal through IMR and want help building medical case
- • Insurance is delaying authorization beyond legal timeframes
- • You're receiving medical bills for work injury treatment
- • Insurance terminated medical treatment claiming you're at MMI but you're not
- • You're stuck in MPN with bad doctors and can't get adequate treatment
- • You need expensive future care and aren't sure whether to close medical in settlement
Free consultations. We'll review your medical treatment issues, explain your options, and fight to get you the care you need.