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Frequently Asked Questions about the New York Workers’ Compensation Medical Treatment Guidelines

When you have a valid workers’ compensation claim in the state of New York, you are entitled to payment of or reimbursement for all “reasonable and necessary” medical treatment. That includes doctor visits, hospital or urgent care facility expenses and even medication costs. There are specific guidelines to inform medical caregivers regarding what types of treatment may be given and what procedures must be followed. Here are some of the commonly asked questions about the New York workers’ compensation medical treatment guidelines.

Q: What is the purpose of the New York workers’ compensation medical treatment guidelines?  

A: The guidelines establish the standard of care that injured workers are entitled to receive. Established in 2010 and supplemented in 2013, they are based on both medical evidence and the input of medical professionals. The guidelines were set forth to ensure a single standard of care for injured workers, to improve medical outcomes and to ensure that injured workers get timely treatment for work-related injuries.

Q: Must the guidelines be followed at all times?

A: In general, all treating medical personnel must follow the guidelines when providing care for any work-related injury. However, in situations where an injured worker requires emergency care, the guidelines may not apply. The guidelines apply regardless of the whether the employer had private workers’ compensation insurance or was self-insured, or whether the claim was filed through any special fund, including the State Insurance Fund.

Q: My injury requires long-term medical care. Do the guidelines continue to apply?

A: Yes. The guidelines cover what is referred to as “ongoing maintenance care.” This is defined as a course of treatment designed to keep an injured person functional and to prevent further deterioration. To qualify for the ongoing maintenance care program, an injured worker must have reached maximum medical improvement, but have a permanent disability. The claimant must also demonstrate chronic pain and show that there would be a decline in his or her condition without the ongoing maintenance care.

Q: Must All Treatment be Authorized in Advance?

A: No. Any procedures or testing that are consistent with the general guidelines, and that are reasonable and necessary are considered to be pre-authorized.  Pre-authorization is only mandatory for specifically identified procedures. A medical provider can, however, seek and obtain prior approval before rendering services.

Effective Workers’ Compensation Lawyers in Queens, New York

At Pyrros & Serres, we offer over 50 years of combined workers’ compensation experience to injured workers throughout Queens and across the greater New York City area. We emphasize personal service and attention, taking the time to learn what happened, so that we can customize our representation to get the results you want. We get many of our new cases as referrals from doctors, lawyers and satisfied clients.

We take all types of work-related injury claims, including cases involving:

Occupational Disease or Illness | Traumatic Brain Injury (TBI) | Fractures | Hip, Leg, Foot and Toe Injury| Burns | Paralysis | Spinal Cord Injury | Permanent Scarring or Disfigurement | Amputation or Loss of Limb | Hearing or Vision Loss | Back and Neck Injury | Shoulder, Arm, Hand and Finger Injury | Accidental or Wrongful Death

To learn more about the services we provide, see our practice area overview page.

Pyrros & Serres LLP

Workers’ Compensation Attorneys—Queens, New York

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