Medical Treatment Guidelines
Medical Treatment Guidelines FAQ
- What is the purpose of the treatment guidelines?
The purpose of the treatment guidelines is to facilitate evidence-based,
safe and appropriate medical treatment of work-related injuries and
occupational diseases, in order to expedite
recovery of health and return to work.
- Why has the Department of Workers’ Claims established the treatment guidelines?
House Bill 2 (2018) mandated that the commissioner of the Department of
Workers’ Claims develop or adopt practice parameters or evidence-based
guidelines for use by medical providers under KRS Chapter 342 (the Workers’
Compensation Act). That legislation further required
the commissioner to promulgate administrative regulations to implement the guidelines
on or before December 31, 2019. The commissioner
has adopted the ODG by MCG Health (“ODG”) medical treatment guidelines for this
- What are the ODG guidelines?
guidelines contain independent, evidence-based, nationally recognized treatment
guidelines for the most common work-related injuries and conditions. ODG
published its first treatment guidelines in 2003. Since then, ODG’s treatment
guidelines, and/or the drug formulary included as Appendix A to the guidelines,
have been adopted by 11 state workers’ compensation systems including Kentucky. ODG’s guidelines are web-based and can be found at www.odgbymcg.com.
- What can I expect to find in ODG?
treatment guidelines contain a comprehensive list of
treatments that may be prescribed for injuries to specific body parts or for general conditions based on
diagnosis. The guidelines are organized by body system. Potential treatment procedures are
listed as either recommended, not recommended, or conditionally recommended. Each guideline is based on a comprehensive
and ongoing review of medical literature that
is ranked in terms of its scientific medical reliability. The methodology used
by ODG can be found in Appendix B of the treatment guidelines, https://www.odgbymcg.com/documents/Methodology.pdf. ODG provides
regular training webinars, and additional training tools can be found for
subscribers at www.odgbymcg.com or the public at www.odgbymcg.com
- Who develops and authors the guidelines?
treatment guidelines are created by independent physicians and healthcare
professionals trained in the review and analysis of evidence-based medical
studies and literature. ODG relies on an Editorial
Advisory Board composed of approximately 100 health care professionals. The
Editorial Advisory Board is multidisciplinary in scope, representing the medical specialties most-commonly involved in
treating workplace injuries and occupational diseases (occupational
medicine, neurosurgeons, orthopedic surgeons,
physical therapists, chiropractors, etc.). Unlike medical specialty society
guidelines, ODG does not represent the interests of any one provider-group over
others. Rather, it represents the wide multitude of specialties involved
in the treatment of injured workers.
- Are the ODG treatment guidelines evidence-based?
Yes, ODG is evidence-based and each treatmentrecommendation is linked to the supporting medical evidence.
Each guideline includes links to the underlying medical studies, provided in abstract form, which are ranked, highlighted, and
indexed. Full text copies of these studies are used by physician editors in
formulating recommendations and are available on request. Procedures for
suggesting changes to the guidelines can be found at https://www.odgbymcg.com/documents/SuggestingChanges.pdf.
- How are the ODG treatment guidelines developed?
The ODG treatment guidelines are developed according to the AGREE
Instrument. AGREE stands for “Appraisal of Guidelines Research and
Evaluation". It originates from an international collaboration of
researchers and policy makers who work together to improve the quality and
effectiveness of clinical practice guidelines by establishing a shared framework
for their development, reporting, and assessment. Further details concerning ODG’s methodology are
provided in Appendix B of the guidelines, which may be found at https://www.odgbymcg.com/documents/Methodology.pdf.
- How often is ODG updated?
ODG is continuously updated.
Beginning in 2021, ODG will utilize a quarterly publishing schedule,
reflecting the findings of new studies as they are conducted and released. In addition to the supporting evidence, each
guideline includes the date on which it was last updated. Further, ODG undergoes a
comprehensive annual update process based on scientific medical literature
review, claims data analysis, and expert panel validation.
- How can I access ODG?
is a subscription-based website. Individuals or companies can purchase licenses
to access ODG on the Web. ODG is also
available for integration into software platforms. The
ODG treatment guidelines and drug formulary can be found for subscribers at www.odgbymcg.com,
and subscription inquiries can be made at www.mcg.com/odg. Questions
concerning subscriptions may also be submitted to the ODG Help Desk at firstname.lastname@example.org, or
by telephone to (800) 488-5548 or (760) 753-9992. The ODG State formulary is
available without subscription at https://wwws.odgbymcg.com/state-formulary.
- What is the cost of an ODG license?
for ODG are typically licensed on an annual basis, and prices vary based on
organizational size and type, as measured by the number of claims management
and/or medical staff (i.e. healthcare providers and/or case managers). Kentucky individual subscribers
receive 50% off the current subscription price.
- When do the treatment guidelines go into effect?
- What is preauthorization?
Preauthorization means the process whereby payment for a medical service
or course of treatment is assured in advance by the insurance carrier.
- What happens when you do not receive preauthorization?
The medical provider who has requested preauthorization may request a
reconsideration of the preauthorization denial and may request a peer-to-peer
telephone conference with a reviewing physician. Denials at the preauthorization stage may
occur for reasons unrelated to medical necessity, such as lack of work-relatedness
or non-compensability of the claim.
- Is preauthorization always required for treatment?
For treatment designated as “Recommended” in the ODG guidelines, preauthorization
is not required. For Treatment
designated as “Not Recommended,” preauthorization is required. When a request is made for preauthorization
for treatment designated as “Conditionally Recommended,” the insurance company
must consider any sound medical reasoning submitted by the medical provider and
may not deny preauthorization based solely on the basis that conditions
precedent have not been met.
- If a treatment is not recommended by ODG is it possible the treatment could still be provided?
Yes. While the ODG guidelines offer the most current evidence based
medical treatment guidance, there are situations where injured workers require
medical care outside of the ODG treatment guidelines. In these situations,
where the medical care is a variance to or outside the scope of ODG, the health
care provider should document the treatment planning rationale according to ‘Documentation
requirements for exceptions,’ which can be found at https://www.odgbymcg.com/documents/DocumentingExceptions.pdf.
- What is the difference between preauthorization and utilization review (UR)?
Preauthorization is defined in the section above. Utilization review means a review of the
medical necessity and appropriateness of medical care and services for purposes
of recommending payments for a compensable injury or disease. The UR process
will result in the treatment being either “certified” (approved) of
- Can an injured worker or a medical provider appeal a UR denial of treatment?
Yes. Either may request
reconsideration of the denial and the medical provider may request a telephone
conference with the physician performing the UR reconsideration. If such a request is made, the medical
provider will select the date and time for the conference and the reviewing
physician must be of the same medical specialty as the treating medical
- Whom should I contact if I have a question about the treatment guidelines?
Questions may be directed to, Scott C. Wilhoit, Division of Specialist
& Medical Services, 502-564-5550 or Scott.Wilhoit@ky.gov. Questions
concerning the ODG by MCG platform and/or subscriptions should be directed to
the ODG Help Desk at email@example.com, or by telephone to
(800) 488-5548 or (760) 753-9992.