Necessity of Treatment

Necessity of treatment provisions can be found in §102.16 (2m), Wis. Stats., and are further detailed in Wis. Admin. Code § DWD 80.73.

The provider must file the dispute with the department within nine (9) months from the date they first received notice from the insurer or self-insured employer denying payment of the provider's bill. (Necessity of Treatment Dispute Resolution Request Form WKC-9380)

WC Treatment Guidelines

The Worker's Compensation Treatment Guidelines in ch. DWD 81 of the Wisconsin Administrative Code were created and are to be used for one very limited purpose. The Treatment Guidelines are factors for an impartial health care services review organization or a member from an independent panel of experts to consider in rendering opinions to resolve necessity of treatment disputes between health care providers and insurance carriers or self-insured employer under s. 102.16 (2m), Wis. Stats., and s. DWD 80.73 of the Wisconsin Administrative Code.

There is no statutory authority allowing the use of the Treatment Guidelines for utilization of treatment reviews to deny treatment outside of the necessity of treatment dispute resolution process. Any action by an insurance carrier or self-insured employer to deny treatment solely based on the Treatment Guidelines in ch. DWD 81 of the Wisconsin Administrative Code, and not through the necessity of treatment dispute process, cannot be enforced or upheld under the Wisconsin Worker's Compensation Act.

Due to the ever-changing and expansive world of health care, not every health care service is covered in these guidelines. The absence of a health care service in the Treatment Guidelines should not be interpreted as meaning that the treatment is not compensable. Under s. 102.42 (1), Wis. Stats., the employer and insurance carrier are liable for necessary treatment reasonably required to cure and relieve the employee from the effects of a work injury. This obligation continues as required to prevent further deterioration in the condition of the employee or to maintain the existing status of the condition whether or not the employee has reached an end of healing.

Chapter DWD 81: Worker's Compensation Treatment Guidelines

 

Necessity of Treatment is in dispute:

REQUEST FOR INDEPENDENT REVIEW (Letter GL92):

REQUEST FOR DEFAULT ORDER: LATE NOTICE - OVER 60 DAYS (Guide Letter GL97):

NOTE: By law, when the provider files the dispute application with the department, the provider must, at the same time, send or deliver a copy of all materials submitted with the dispute application to the insurer or self-insured employer who is refusing to pay for the treatment it considers unnecessary.

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