A variance request should be filed if the treating provider believes that treatment is required that is not recommended under the Guidelines or that exceeds the frequency/duration limits under the Guidelines. A variance request or prior authorization from the insurance carrier is NOT required for treatment recommended under the Guidelines, as it is considered by the Board to be pre-approved.
Remember also that the Board has recently stated that treatment of an exacerbation does NOT require a variance request, as long as the treatment provided falls under the acute/subacute Guidelines. (See Treatment of an Exacerbation for Injuries Covered by The Medical Treatment Guidelines.)
It is very important that your variance request be fully and correctly completed so that there is no unnecessary delay in the patient’s treatment. The Board has directed that a complete and accurate MG-2 form must include:
The variance form must include the medical treatment guideline reference, indicating the body part (B for Back, N for Neck, S for Shoulder, K for Knee) in the first box and followed by at least two subset codes in the remaining boxes, depending upon the body part.
e.g., a variance request for Back Massage (Manual or Mechanical) has four possible MTG references, each with four subset codes: [B]-[D][c][i] or [B]-[D][c][ii] or [B]-[D][c][iii] or [B]-[D][c][iv], while Testing Procedures for a Knee Meniscus Injury has one MTG reference code with three subset codes[K]-[D][d][ ]
If the variance is requested for a body part covered in the MTG, but the procedure or treatment is not addressed in the guidelines, the Medical Provider should use the appropriate MTG body part letter only in the first box and the word NONE in the subsequent boxes (e.g., [B]-[N][O][N][E]).
The Guideline Reference codes can be found in the index and text of the Medical Treatment Guidelines.
The “burden of proof” lies with the treating provider when documenting the medical necessity of treatment that is not recommended or that exceeds the Guidelines. This is the area due to which most variance requests are denied. The Board has defined what criteria and documentation are required to meet the burden of proof:
The treating provider must not only show why the treatment he is recommending is appropriate; the provider also must show why other treatment recommended under the Guidelines is not appropriate or sufficient. For example, a statement could be made that “X Therapy is contraindicated for this condition” or “X Therapy was attempted but did not improve the patient’s condition or “The patient has been evaluated by a surgeon and was not found to be a surgical candidate”.”
Additionally, objective measures of functional improvement are defined in the Guidelines as positive patient responses that “primarily consist of functional gains which can be objectively measured and include, but are not limited to, positional tolerances, range of motion, strength, endurance, activities of daily living, cognition, psychological behavior, and efficiency/velocity measures which can be quantified.”
Subjective reports of pain and function can also be helpful, provided the patient accurately reflects their condition in their personal assessments. Examples of subjective outcome measures include:
The Board has provided a Sample completed MG-2 form that may be helpful in demonstrating what a fully and correctly completed form looks like.