New york state workers compensation journal for medical professionals and their staff

The MG-2 and MG-2.1 Forms: When and How to Complete a Variance Request

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.)

Appropriate Completion of Form MG-2

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:

  • Claimant’s name;
  • Doctor’s signature or stamp, WCB Authorization Number and fax number;
  • Date and method of transmission (if a fax number is provided, the certification box checked for method of transmission must be “by fax,” not “by mail” in section “C”);
  • Guideline Reference (for clarification see details below);
  • Treatment for which approval is requested;
  • Statement of medical necessity (either a written description or documentation attached to the MG-2 form or reference a date of service in the WCB file where the supporting medical documentation can be found);
  • And completion of one of two boxes certifying that the form was faxed or emailed to carrier/employer/self-insured employer/special fund or box checked that provider does not have fax or e-mail capability and the date that copies were mailed.

Medical Treatment Guideline Reference

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][10][c][i] or [B]-[D][10][c][ii] or [B]-[D][10][c][iii] or [B]-[D][10][c][iv], while Testing Procedures for a Knee Meniscus Injury has one MTG reference code with three subset codes[K]-[D][6][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.

Supporting Medical Documentation

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:

  1. For all variances:
    1. medical opinion, including the basis for the opinion, that the proposed medical care that varies from the MTG is appropriate and medically necessary, and
    2. a statement that the claimant agrees to the proposed medical care (I don’t quite understand this requirement, as the MG-2 form states in its certification section: “I certify that the claimant understands and agrees to undergo the proposed medical care,” but this is what the Board has stated is required), and
    3. an explanation of why alternatives under the MTG are not appropriate or sufficient, and
  2. For appropriate claims:
    1. a description of any signs or symptoms which have failed to improve with previous treatments provided in accordance with the MTG; or
    2. if the variance involves frequency or duration of a particular treatment, a description of the functional objective outcomes that, as of the date of the variance request, have continued to demonstrate objective improvement from that treatment and are reasonably expected to further improve with additional treatment.

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.

6 Responses to “The MG-2 and MG-2.1 Forms: When and How to Complete a Variance Request”

  1. edward chapman says:

    my dr issued an mgt2 form to you for physical therapy but it was denied because something was wrong with the way it was filed would you please tell me the proper way so that I may give that info to my dr so I can get the necessary treatment. it is a damn shame that you people cant get things right it is the patients that suffer you all are alright one day this might happen to you and you’ll be sitting doing what I am doing now

    • Elizabeth says:

      The submission instructions are found on the back of the MG2 form. Unfortunately, without knowing exactly the reason for the denial, that is the best reference I can give to you

  2. audrey haynes says:

    We are physical Therapist trying to fill out an MG-2 to sent to MD for approval and submission to insurance carrier.
    Can you clarify if an additional variance must be populated for each type of service, i.e. hot/cold pack, stimulation, ultrasound, exercise and manual therapy if they are not under the same guidelines?
    Thank you for your input.

    • Elizabeth says:

      Each item must be requested separately and specifically. If the variance is for the same time frame, you can submit a single MG-2 and append a completed MG-2.1 for each additional service.

  3. Jennifer says:

    Can you please tell me which of the variance forms we would need to file in order to request an MRI for our patient, or if both the MG 2 AND the MG 2.1 are needed for this request? Thank you

    • Elizabeth says:

      If you are only requesting one service to one area of the body, you only need to submit the MG-2. Form MG-2.1 should be submitted for additional services as needed, but must be attached to a completed Form MG-2 when requesting approval for additional variance(s) in the same case. Supporting medical must be attached or identified for each request.

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