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| Home
> Attorneys
and Insurers > Current
Guidelines > Milliman and Robertson |
| Milliman and Robertson is often used to deny
Chiropractic services, especially within the Worker's Compensation
system. However, it must be understood that M&R DOES NOT pertain to
chronic pain conditions. M&R guidelines are a set of optimal benchmarks
for treating common conditions for patients who have no complications.
Essentially they only relate to (1) non-complicated, (2) acute pain
patients, who are (3) off work. There are several points within the updated Bulletin published by M&R that are important to consider when faced with reviewer/nurse/claims administrators who inappropriately reference M&R as a reason to deny treatment for a complicated chronic work-related injury. The following paragraphs are within the Bulletin. "The Guidelines are written in a clear direct style because they are, quite simply, guidelines for providing the right care, at the right time, and in the right setting." "They are not a prescription, a decision tree, or a set of rules for the practice of medicine." "In no situation are the Guidelines intended to be a substitute for sound clinical judgment based on an individual patient's condition." "Rather than rationing or reducing care, the goal of the Guidelines is to provide a patient with the best care possible." "When the M&R Guidelines are cited to the provider in the context of a denial notice, that notice must contain reasons for denial, including an easily understood summary of the applicable utilization management decision criteria from the Guidelines used. It must also include how the guideline cited is applied to the specific patient's condition. When a payor adopts this approach, both the provider and the patient are able to understand fully the rationale for the healthcare organizations decision." "Our licensing agreements require that all coverage decision communications that reproduce or cite any part of the Guidelines must contain the following statement: M&R Care Guidelines are not intended to be used without the judgment of a qualified, healthcare professional taking into account the individual circumstances of each patient's case." "Anyone who uses the Guidelines as the sole basis for denying authorization for treatment without proper consideration of the unique characteristics of each patient or as the sole basis for denying payment for treatment received is using our Guidelines inappropriately." |