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.
What Medical Treatment Is Covered? Comprehensive List
Under Labor Code §4600, California employers must provide all medical treatment "reasonably required to cure or relieve" effects of a work injury. The following is a comprehensive breakdown of every category of treatment the law covers:
| Treatment Category | Examples | Authorization Required? |
|---|---|---|
| Surgical | Spinal fusion, rotator cuff repair, knee arthroscopy, carpal tunnel release, joint replacement | Yes (except emergencies) |
| Physical Therapy | PT, OT, aquatic therapy, work hardening, functional restoration | Initial 24 visits usually auto-approved; more requires RFA |
| Medications | NSAIDs, opioids, muscle relaxants, nerve pain meds, topicals, antidepressants for pain | Prior auth for some; generics preferred |
| Chiropractic | Spinal manipulation, adjustments, modalities (heat/ice/e-stim) | 24 visits/year presumed reasonable; more requires UR |
| Psychiatric / Psychological | PTSD therapy, anxiety counseling, psychiatric medication management, pain-related depression | Yes; must be linked to work injury |
| Pain Management | Epidural injections, nerve blocks, facet joint injections, radiofrequency ablation, TENS units | Yes for all injection-based procedures |
| Diagnostic | MRI, CT scan, X-ray, EMG/NCV, blood work, bone density scans | Advanced imaging yes; basic X-ray usually no |
| Durable Medical Equipment | Braces, crutches, wheelchairs, prosthetics, CPAP, ergonomic equipment | Doctor prescription required; major items need RFA |
| Home Health Care | In-home nursing, home PT, attendant care, aide services | Yes; typically for severe/catastrophic injuries only |
| Acupuncture | Acupuncture sessions prescribed by treating physician | Yes; must be prescribed and authorized |
Can I Choose My Own Doctor?
Your ability to choose your treating physician is one of the most important rights in your workers' comp case, because the doctor who treats you also writes the reports that determine your disability rating and settlement value. Understanding the rules around doctor selection can significantly impact your outcome.
Pre-Designation: The Best Way to Protect Yourself
Before an injury occurs, you can pre-designate your personal physician as your workers' comp treating doctor by providing written notice to your employer. This is the strongest way to maintain control over your medical care. Requirements:
- • You must have health insurance coverage (not workers' comp) at the time of pre-designation
- • The doctor must have previously directed your medical treatment and maintained your medical records
- • You must notify your employer in writing before the injury occurs
- • The pre-designated doctor must agree to treat you for workers' comp
Medical Provider Networks (MPN): The Employer's System
Most California employers use a Medical Provider Network (MPN) -- a pre-approved list of doctors, specialists, and facilities that you must choose from for your treatment. If your employer has an MPN and you did not pre-designate, the MPN rules control your doctor choice:
- • Must choose from MPN list initially (employer must provide at least 3 physicians in each specialty within 30 miles)
- • Can request a one-time change of doctor within the MPN after 30 days
- • Can request a second opinion from another MPN doctor if you disagree with treatment
- • Can go outside the MPN if no specialist in your area or for specific medical needs the MPN cannot accommodate
Important: The doctor you see for treatment is different from the doctor who evaluates your disability rating. If your case is disputed, a Qualified Medical Evaluator (QME) or Agreed Medical Evaluator (AME) will independently assess your permanent disability -- and that evaluation can dramatically change your settlement value.
What If Treatment Is Denied?
Treatment denials are unfortunately common. Insurance companies use Utilization Review (UR) -- established under Labor Code §4610 -- to evaluate whether your doctor's recommended treatment is "medically necessary." UR doctors are hired by insurance companies, never examine you, and deny 40-60% of treatment requests. But a denial is not the end -- it's the beginning of the appeals process.
Step 1: Understand Why the Denial Occurred
Every UR denial must come with a written explanation citing specific medical reasons. Common denial grounds include:
- • "Not medically necessary" (UR doctor disagrees with your treating doctor's medical judgment)
- • "Not within MTUS guidelines" (treatment doesn't follow the Official Medical Treatment Utilization Schedule)
- • "Conservative treatment not exhausted" (insurance wants you to try cheaper options first)
- • "Pre-existing condition" (claiming the body part was already damaged before work)
- • "Not related to industrial injury" (questioning whether work caused the problem)
Step 2: File for Independent Medical Review (IMR)
You have 30 days from the UR denial to file for IMR. An independent physician -- not paid by insurance -- reviews your case and makes a binding decision. Workers win approximately 60% of IMR appeals. If the IMR doctor approves treatment, insurance must authorize it within 5 business days.
Step 3: If IMR Fails, Pursue Other Remedies
If IMR also denies treatment, your attorney can:
- • Request your treating doctor submit a new RFA with additional supporting evidence
- • Obtain a QME evaluation to support medical necessity
- • File an Expedited Hearing at the WCAB for urgent treatment needs
- • Submit medical literature and studies supporting the treatment
Insurance companies count on injured workers giving up after a denial. Don't. Learn more about common insurance company tactics designed to delay, deny, and minimize your benefits.
The Utilization Review Process Explained
Utilization Review is the mechanism insurance companies use to control medical costs -- and often to improperly deny treatment. Understanding how UR works empowers you to fight back effectively.
How the UR Process Works:
Your Doctor Submits an RFA
Your treating physician determines you need a specific treatment (surgery, MRI, injections, etc.) and submits a formal Request for Authorization to the insurance company with supporting medical documentation.
Insurance Sends RFA to UR Doctor
A physician employed or contracted by the insurance company -- who has never examined you and likely practices in a different specialty -- reviews your medical records and your doctor's request against the MTUS guidelines.
UR Doctor Issues Decision
Timelines: 72 hours for urgent/concurrent requests, 5 business days for standard prospective requests, 30 days for retrospective review. If insurance misses these deadlines, the treatment is deemed authorized by law.
You Receive Written Denial (If Denied)
The denial letter must include the specific clinical rationale, the MTUS guidelines relied upon, and instructions for filing an IMR appeal. If the letter is missing any of these elements, the denial may be invalid.
Your Appeal Rights Begin
You have 30 days to file IMR. Your attorney can also request a peer-to-peer review (where your treating doctor speaks directly with the UR doctor) or submit additional medical evidence to support the request.
The Reality of UR: Built to Deny
UR doctors are financially incentivized to deny treatment. They review hundreds of cases per week, spend minutes on each, and never see the patient. Their denial rates can exceed 50%. This is why having an attorney who understands how insurance companies operate is critical to getting the medical care you need.
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
- • Your doctor recommended treatment but insurance wants a QME evaluation first
- • You want to understand how treatment decisions affect your permanent disability rating
Free consultations. We'll review your medical treatment issues, explain your options, and fight to get you the care you need.