# Medical Treatment Guidelines Aggregated by Superinsight from public-domain sources, as of 2026-09-02. Domain: wc/ny. --- ## 12 NYCRR § 324.1 — Definitions {#324.1} *N.Y. Comp. Codes R. & Regs. tit. 12, § 324.1* Official source: _Aggregated from public-domain New York law; last amended effective 2021-06-07._ (a) The definitions of the terms in section 300.1(a) of this Title are applicable to this Subchapter. (b) Calendar day means the time period from midnight to midnight. For the purposes of calculating calendar days, the day of submission is day zero and the first calendar day begins at midnight following the submission. (c) Carrier's Physician means a physician or physicians, licensed by New York State, or the appropriate state where the professional practices, who is: 1. employed or contracted by the insurance carrier, self-insured employer, or third-party administrator; or 2. employed by a URAC accredited company retained by the insurance carrier, self-insured employer, or third-party administrator through a contract to review prior authorization requests and advise the insurance carrier, self-insured employer, or third-party administrator; and 3. is not employed or contracted by the carrier, self-insured employer, or third-party administrator's recommendation of care network. 1. employed or contracted by the insurance carrier, self-insured employer, or third-party administrator; or 2. employed by a URAC accredited company retained by the insurance carrier, self-insured employer, or third-party administrator through a contract to review prior authorization requests and advise the insurance carrier, self-insured employer, or third-party administrator; and 3. is not employed or contracted by the carrier, self-insured employer, or third-party administrator's recommendation of care network. (d) Consistent with the Medical Treatment Guidelines means within the criteria of the Medical Treatment Guidelines and based on a correct application of the Medical Treatment Guidelines. (e) Denial, deny or denies means a denial or a partial approval by an insurance carrier, self-insured employer, or third-party administrator of a Prior Approval Request, defined herein, made pursuant to section 324.3 of this Part or a prior approval request made pursuant to section 324.4 of this Part. (f) Maximum Medical Improvement (MMI) means a medical judgment that (1) a claimant has recovered from the work injury to the greatest extent that is expected and (2) no further improvement in his or her condition is reasonably expected. The need for palliative or symptomatic treatment does not preclude a finding of MMI. In cases that do not involve surgery or fractures, MMI cannot be determined prior to six months from the date of injury or disablement, unless otherwise agreed to by the parties. A finding of maximum medical improvement is a normal precondition for determining the permanent disability level of a claimant. (1) a claimant has recovered from the work injury to the greatest extent that is expected and (2) no further improvement in his or her condition is reasonably expected. The need for palliative or symptomatic treatment does not preclude a finding of MMI. In cases that do not involve surgery or fractures, MMI cannot be determined prior to six months from the date of injury or disablement, unless otherwise agreed to by the parties. A finding of maximum medical improvement is a normal precondition for determining the permanent disability level of a claimant. (g) Medical Director's Office means the Medical Director of the Board, the Executive Medical Policy Director, the Assistant Medical Director of the Board, or their designee. (h) Medical care means all care, treatment, and other attendance for an injured worker's injury, illness or occupational disease as listed and provided in Workers' Compensation Law Sections 13, 13-b, 13-k, 13-l, and 13-m. (i) Medical Treatment Guidelines means the treatment guidelines for workers' compensation injuries, illnesses, or occupational diseases to the parts of the body addressed in the guidelines incorporated by reference in section 324.2(a) of this Part. (j) Prior Authorization means the carrier, self-insured employer, or third-party administrator's approval of a Prior Authorization request initiated by the medical provider. (k) Carrier's physician's medical report means the evaluation of a claimant without physical examination, by the Carrier's physician, based on the review of reports and records, including treatment notes, diagnostic test results, depositions or hearing testimony, exhibits, and other records or reports from medical providers or independent medical examiners or both in the electronic case file maintained by the Board. (l) Prior Authorization Request (PAR) shall mean any of the following: a variance request (PAR: MTG Variance) or a request for special services (PAR: Special Services) made pursuant to section 324.3 herein, or a request confirming consistency with Medical Treatment Guidelines (PAR: MTG Confirmation) or confirming medical necessity when there is no Medical Treatment Guideline that addresses treatment for the body part or condition and the treatment costs less than $1000 ( PAR: Non-MTG $1,000 or Under) as defined in 324.4. "Prior Authorization Request" or "PAR" may also mean a prior authorization request for medical care costing more than $1000 when there is no Medical Treatment Guideline that addresses treatment for the body part or condition (PAR: Non-MTG Over $1,000) made pursuant to section 325-1.4 of this Chapter. (m) Treating medical provider means a duly licensed acupuncturist, chiropractor, nurse practitioner, occupational therapist, physical therapist, physician, physician assistant, podiatrist, psychologist, or social worker authorized by the chair, as such terms are defined in section 13-b of the workers' compensation law, or any provider not permitted to obtain authorization in New York State and who has not surrendered or had a Board authorization suspended or revoked, and (1) is licensed pursuant to the education law to provide medical care and treatment in the state of New York, or (2) is duly licensed pursuant to the laws of another state to provide medical care and treatment, who is providing treatment and care to an injured worker pursuant to the Workers' Compensation Law. --- ## 12 NYCRR § 324.2 — Medical treatment guidelines {#324.2} *N.Y. Comp. Codes R. & Regs. tit. 12, § 324.2* Official source: _Aggregated from public-domain New York law; last amended effective 2023-06-21._ (a) Medical Treatment Guidelines. Regardless of the date of accident or date of disablement, treatment of on the job injuries, illnesses, or occupational diseases shall be consistent with the applicable Medical Treatment Guidelines set forth herein. The operative Medical Treatment Guidelines shall be the Medical Treatment Guidelines in place on the date on which medical services are rendered. All Treating Medical Providers shall treat all existing and new workers' compensation injuries, illnesses, or occupational diseases, except as provided in section 324.3 of this Part, in accordance with the following: (1) for the lumbar and thoracic spine before May 2, 2022, the New York Mid and Low Back Injury Medical Treatment Guidelines, Third Edition, September 15, 2014, effective November 1, 2014, which is herein incorporated by reference; for lumbar and thoracic spine treatment rendered on or after May 2, 2022, the New York Mid and Low Back Injury Medical Treatment Guidelines, Fourth Edition, January 26, 2021, effective May 2, 2022, which is herein incorporated by reference; (2) for the cervical spine before May 2, 2022, the New York Neck Injury Medical Treatment Guidelines, Third Edition, September 15, 2014, effective November 1, 2014, which is incorporated herein by reference; for cervical spine treatment rendered on or after May 2, 2022, the New York Neck Injury Medical Treatment Guidelines, Fourth Edition, January 26, 2021, effective May 2, 2022, which is herein incorporated by reference; (3) for the knee before May 2, 2022, with the New York Knee Injury Medical Treatment Guidelines, Third Edition, September 15, 2014, effective November 1, 2014, which is incorporated herein by reference; for knee treatment rendered on or after May 2, 2022, the New York Knee Injury Medical Treatment Guidelines, Fourth Edition, January 26, 2021, effective May 2, 2022, which is herein incorporated by reference; (4) for the shoulder before May 2, 2022, the New York Shoulder Injury Medical Treatment Guidelines, Third Edition, September 15, 2014, effective November 1, 2014, which is incorporated herein by reference; for shoulder treatment rendered on or after May 2, 2022, the New York Shoulder Injury Medical Treatment Guidelines, Fourth Edition, January 26, 2021 effective May 2, 2022, which is herein incorporated by reference; (5) for treatment of carpal tunnel syndrome before May 2, 2022, the New York Carpal Tunnel Syndrome Medical Treatment Guidelines, Second Edition, September 15, 2014, effective November 1, 2014, which is incorporated herein by reference; (6) for non-acute pain before May 2, 2022, the New York Non-Acute Pain Medical Treatment Guidelines, First Edition, September 15, 2014, effective November 1, 2014, which is incorporated herein by reference; for non-acute pain treatment rendered on or after May 2, 2022, the New York Non-Acute Pain Medical Treatment Guidelines, Second Edition, March 25, 2021, effective May 2, 2022, which is herein incorporated by reference; (7) for the hip and groin, the New York Hip/Groin Medical Treatment Guideline, First Edition, March 18, 2020, effective May 2, 2022, which is incorporated herein by reference; (8) for the foot and ankle, the New York Foot/Ankle Medical Treatment Guideline, First Edition, March 18, 2020, effective May 2, 2022, which is incorporated herein by reference; (9) for the elbow, the New York Elbow Medical Treatment Guideline, first edition, March 18, 2020 effective May 2, 2022, herein incorporated by reference; (10) for occupational interstitial lung disease, the New York Occupational Interstitial Lung Disease Medical Treatment Guideline, first edition, March 18, 2020, effective May 2, 2022, herein incorporated by reference; (11) for asthma, the New York Asthma Medical Treatment Guideline, first edition, May 12, 2020, effective May 2, 2022, herein incorporated by reference; (12) for hand, wrist and forearm, including treatment for carpal tunnel syndrome rendered on or after May 2, 2022, the New York Hand, Wrist & Forearm Medical Treatment Guideline, first edition, May 12, 2020, effective May 2, 2022, herein incorporated by reference; (13) for post-traumatic stress disorder and acute stress disorder, the New York Post-traumatic Stress Disorder and Acute Stress Disorder Medical Treatment Guideline, first edition, September 15, 2020, effective May 2, 2022, herein incorporated by reference; (14) for depression, the New York Work-Related Depression and Depressive Disorders Medical Treatment Guideline, first edition, September 15, 2020, effective May 2, 2022, herein incorporated by reference; (15) for eye disorders, the New York Eye Disorders Medical Treatment Guidelines, first edition, September 28, 2021, effective May 2, 2022, herein incorporated by reference; (16) for traumatic brain injury, the New York Traumatic Brain Injury Medical Treatment Guidelines, first edition, September 28, 2021, effective May 2, 2022, herein incorporated by reference; and (17) for complex regional pain syndrome, the New York Complex Regional Pain Syndrome Medical Treatment Guidelines, first edition, September 28, effective May 2, 2022, herein incorporated by reference. (1) for the lumbar and thoracic spine before May 2, 2022, the New York Mid and Low Back Injury Medical Treatment Guidelines, Third Edition, September 15, 2014, effective November 1, 2014, which is herein incorporated by reference; for lumbar and thoracic spine treatment rendered on or after May 2, 2022, the New York Mid and Low Back Injury Medical Treatment Guidelines, Fourth Edition, January 26, 2021, effective May 2, 2022, which is herein incorporated by reference; (2) for the cervical spine before May 2, 2022, the New York Neck Injury Medical Treatment Guidelines, Third Edition, September 15, 2014, effective November 1, 2014, which is incorporated herein by reference; for cervical spine treatment rendered on or after May 2, 2022, the New York Neck Injury Medical Treatment Guidelines, Fourth Edition, January 26, 2021, effective May 2, 2022, which is herein incorporated by reference; (3) for the knee before May 2, 2022, with the New York Knee Injury Medical Treatment Guidelines, Third Edition, September 15, 2014, effective November 1, 2014, which is incorporated herein by reference; for knee treatment rendered on or after May 2, 2022, the New York Knee Injury Medical Treatment Guidelines, Fourth Edition, January 26, 2021, effective May 2, 2022, which is herein incorporated by reference; (4) for the shoulder before May 2, 2022, the New York Shoulder Injury Medical Treatment Guidelines, Third Edition, September 15, 2014, effective November 1, 2014, which is incorporated herein by reference; for shoulder treatment rendered on or after May 2, 2022, the New York Shoulder Injury Medical Treatment Guidelines, Fourth Edition, January 26, 2021 effective May 2, 2022, which is herein incorporated by reference; (5) for treatment of carpal tunnel syndrome before May 2, 2022, the New York Carpal Tunnel Syndrome Medical Treatment Guidelines, Second Edition, September 15, 2014, effective November 1, 2014, which is incorporated herein by reference; (6) for non-acute pain before May 2, 2022, the New York Non-Acute Pain Medical Treatment Guidelines, First Edition, September 15, 2014, effective November 1, 2014, which is incorporated herein by reference; for non-acute pain treatment rendered on or after May 2, 2022, the New York Non-Acute Pain Medical Treatment Guidelines, Second Edition, March 25, 2021, effective May 2, 2022, which is herein incorporated by reference; (7) for the hip and groin, the New York Hip/Groin Medical Treatment Guideline, First Edition, March 18, 2020, effective May 2, 2022, which is incorporated herein by reference; (8) for the foot and ankle, the New York Foot/Ankle Medical Treatment Guideline, First Edition, March 18, 2020, effective May 2, 2022, which is incorporated herein by reference; (9) for the elbow, the New York Elbow Medical Treatment Guideline, first edition, March 18, 2020 effective May 2, 2022, herein incorporated by reference; (10) for occupational interstitial lung disease, the New York Occupational Interstitial Lung Disease Medical Treatment Guideline, first edition, March 18, 2020, effective May 2, 2022, herein incorporated by reference; (11) for asthma, the New York Asthma Medical Treatment Guideline, first edition, May 12, 2020, effective May 2, 2022, herein incorporated by reference; (12) for hand, wrist and forearm, including treatment for carpal tunnel syndrome rendered on or after May 2, 2022, the New York Hand, Wrist & Forearm Medical Treatment Guideline, first edition, May 12, 2020, effective May 2, 2022, herein incorporated by reference; (13) for post-traumatic stress disorder and acute stress disorder, the New York Post-traumatic Stress Disorder and Acute Stress Disorder Medical Treatment Guideline, first edition, September 15, 2020, effective May 2, 2022, herein incorporated by reference; (14) for depression, the New York Work-Related Depression and Depressive Disorders Medical Treatment Guideline, first edition, September 15, 2020, effective May 2, 2022, herein incorporated by reference; (15) for eye disorders, the New York Eye Disorders Medical Treatment Guidelines, first edition, September 28, 2021, effective May 2, 2022, herein incorporated by reference; (16) for traumatic brain injury, the New York Traumatic Brain Injury Medical Treatment Guidelines, first edition, September 28, 2021, effective May 2, 2022, herein incorporated by reference; and (17) for complex regional pain syndrome, the New York Complex Regional Pain Syndrome Medical Treatment Guidelines, first edition, September 28, effective May 2, 2022, herein incorporated by reference. (b) Obtaining the medical treatment guidelines. The New York Medical Treatment Guidelines incorporated by reference herein may be examined at the office of the Department of State, 99 Washington Avenue, Albany, New York, 12231, the Legislative Library, the libraries of the New York State Supreme Court, and the district offices of the Board. Copies may be downloaded from the Board's website without a fee at wcb.ny.gov. (c) Limitations. The Medical Treatment Guidelines in subdivision (a) of this section and this Part are not intended to, and were not prepared with the expectation of, establishing a standard for determining professional liability. (d) Applicability and Pre-authorized procedures list. All medical care consistent with the Medical Treatment Guidelines costing more than $1,000 is included on the pre-authorized procedures list, except as set forth in section 324.3 herein . Medical care costing more than $1,000 included in a Medical Treatment Guideline is pre-authorized so Treating Medical Providers are not required to request prior authorization. Medical care that is not included in the applicable Medical Treatment Guidelines may only be provided in accordance with section 324.3 herein. A Treating Medical Provider may confirm that medical care is consistent with the Medical Treatment Guidelines or, when there is not an applicable Medical Treatment Guideline and the total cost for the aggregate of such medical care is less than $1000, may confirm the medical necessity of causally related medical care by submitting a request in accordance with section 324.4 herein. (e) Variances from the Medical Treatment Guidelines are permissible only as provided in section 324.3 of this Part. (f) Maximum medical improvement shall not preclude the provision of medically necessary care for claimants. Such care shall be medically necessary to maintain function at the maximum medical improvement level or to improve function following an exacerbation of the claimant's condition. Post-maximum medical improvement medical services shall conform to the relevant Medical Treatment Guidelines, except as provided in section 324.3 of this Part. --- ## 12 NYCRR § 324.3 — Variances (PAR: MTG Variances) {#324.3} *N.Y. Comp. Codes R. & Regs. tit. 12, § 324.3* Official source: _Aggregated from public-domain New York law; last amended effective 2023-03-29._ (a) Treating medical providers. (1) Applicability (i) (a) When a treating medical provider determines that medical care that varies from the Medical Treatment Guidelines, such as when a treatment, procedure, or test is not recommended by the Medical Treatment Guidelines, appropriate for the claimant and medically necessary, he or she shall request a variance from the insurance carrier, self-insured employer, or third party administrator by submitting a prior approval request (PAR: MTG Variance) (hereinafter "PAR") in the format prescribed by the chair for such purpose, which may be electronic. (b) In addition, prior authorization for the following special services (PAR: Special Services) is required: (1) Lumbar fusion as set forth in E.4 of the New York Mid and Low Back Injury Medical Treatment Guidelines; (2) Artificial disc replacement as set forth in E.5 of the New York Mid and Low Back Injury Medical Treatment Guidelines, and in E.3 of the New York Neck Injury Medical Treatment Guidelines; (3) Vertebroplasty as set forth in E.6.a.i. of the New York Mid and Low Back Injury Medical Treatment Guidelines; (4) Kyphoplasty as set forth in E.6.a.i. of the New York Mid and Low Back Injury Medical Treatment Guidelines; (5) Electrical bone stimulation as set forth in the New York Mid and Low Back Injury Medical Treatment Guidelines and the New York Neck Injury Medical Treatment Guidelines; (6) Osteochondral autograft as set forth in D.1.f and Table 4 of the New York Knee Injury Medical Treatment Guidelines; (7) Autologous chondrocyte implantation as set forth in D.1.f., Table 5, and D.1.g. of the New York Knee Injury Medical Treatment Guidelines; (8) Meniscal allograft transplantation as set forth in D.6.f., Table 8, and D.7. of the New York Knee Injury Medical Treatment Guidelines; (9) Knee arthroplasty (total or partial knee joint replacement) as set forth in F.2. and Table 11 of the New York Knee Injury Medical Treatment Guidelines; (10) Spinal Cord Pain Stimulators as set forth in G.1 of the Non-Acute Pain Medical Treatment Guidelines; (11) Intrathecal Drug Delivery (Pain Pumps) as set forth in G.2 of the Non-Acute Pain Medical Treatment Guidelines ; (12) Sacroiliac joint (SIJ) fusion as set forth in E.8 of the Mid and Low Back Medical Treatment Guidelines; and (13) Peripheral Nerve Stimulation (PNS) as set forth in G.2 of the Non-Acute Pain Medical Treatment Guidelines. (c) Notwithstanding that a surgical procedure is consistent with the guidelines, a second or subsequent performance of such surgical procedure shall require a PAR: special services if it is repeated because of the failure or incomplete success of the same surgical procedure performed earlier, and if the medical treatment guidelines do not specifically address multiple procedures. (d) This section shall not apply to prior authorization requests from the formulary, as set forth in Part 441 of this chapter, or the durable medical equipment fee schedule, as set forth in Part 442 of this chapter. (ii) A PAR must be requested and granted by the carrier, selfinsured employer, or third-party administrator, the Board or order of the Chair before medical care that varies from the Medical Treatment Guidelines or special service is provided to the claimant and the carrier, self-insured employer, or third-party administrator may deny the PAR and deny payment of the treatment requested if the treatment is rendered prior to the PAR being granted by the carrier, self-insured employer, third-party administrator, the Board or order of the Chair. (iii) For the purposes of this section, a treating medical provider shall not include a physician assistant, acupuncturist, physical therapist, or occupational therapist, as defined in section 13-b. (1) Applicability (i) (a) When a treating medical provider determines that medical care that varies from the Medical Treatment Guidelines, such as when a treatment, procedure, or test is not recommended by the Medical Treatment Guidelines, appropriate for the claimant and medically necessary, he or she shall request a variance from the insurance carrier, self-insured employer, or third party administrator by submitting a prior approval request (PAR: MTG Variance) (hereinafter "PAR") in the format prescribed by the chair for such purpose, which may be electronic. (b) In addition, prior authorization for the following special services (PAR: Special Services) is required: (1) Lumbar fusion as set forth in E.4 of the New York Mid and Low Back Injury Medical Treatment Guidelines; (2) Artificial disc replacement as set forth in E.5 of the New York Mid and Low Back Injury Medical Treatment Guidelines, and in E.3 of the New York Neck Injury Medical Treatment Guidelines; (3) Vertebroplasty as set forth in E.6.a.i. of the New York Mid and Low Back Injury Medical Treatment Guidelines; (4) Kyphoplasty as set forth in E.6.a.i. of the New York Mid and Low Back Injury Medical Treatment Guidelines; (5) Electrical bone stimulation as set forth in the New York Mid and Low Back Injury Medical Treatment Guidelines and the New York Neck Injury Medical Treatment Guidelines; (6) Osteochondral autograft as set forth in D.1.f and Table 4 of the New York Knee Injury Medical Treatment Guidelines; (7) Autologous chondrocyte implantation as set forth in D.1.f., Table 5, and D.1.g. of the New York Knee Injury Medical Treatment Guidelines; (8) Meniscal allograft transplantation as set forth in D.6.f., Table 8, and D.7. of the New York Knee Injury Medical Treatment Guidelines; (9) Knee arthroplasty (total or partial knee joint replacement) as set forth in F.2. and Table 11 of the New York Knee Injury Medical Treatment Guidelines; (10) Spinal Cord Pain Stimulators as set forth in G.1 of the Non-Acute Pain Medical Treatment Guidelines; (11) Intrathecal Drug Delivery (Pain Pumps) as set forth in G.2 of the Non-Acute Pain Medical Treatment Guidelines ; (12) Sacroiliac joint (SIJ) fusion as set forth in E.8 of the Mid and Low Back Medical Treatment Guidelines; and (13) Peripheral Nerve Stimulation (PNS) as set forth in G.2 of the Non-Acute Pain Medical Treatment Guidelines. (c) Notwithstanding that a surgical procedure is consistent with the guidelines, a second or subsequent performance of such surgical procedure shall require a PAR: special services if it is repeated because of the failure or incomplete success of the same surgical procedure performed earlier, and if the medical treatment guidelines do not specifically address multiple procedures. (d) This section shall not apply to prior authorization requests from the formulary, as set forth in Part 441 of this chapter, or the durable medical equipment fee schedule, as set forth in Part 442 of this chapter. (ii) A PAR must be requested and granted by the carrier, selfinsured employer, or third-party administrator, the Board or order of the Chair before medical care that varies from the Medical Treatment Guidelines or special service is provided to the claimant and the carrier, self-insured employer, or third-party administrator may deny the PAR and deny payment of the treatment requested if the treatment is rendered prior to the PAR being granted by the carrier, self-insured employer, third-party administrator, the Board or order of the Chair. (iii) For the purposes of this section, a treating medical provider shall not include a physician assistant, acupuncturist, physical therapist, or occupational therapist, as defined in section 13-b. (i) (a) When a treating medical provider determines that medical care that varies from the Medical Treatment Guidelines, such as when a treatment, procedure, or test is not recommended by the Medical Treatment Guidelines, appropriate for the claimant and medically necessary, he or she shall request a variance from the insurance carrier, self-insured employer, or third party administrator by submitting a prior approval request (PAR: MTG Variance) (hereinafter "PAR") in the format prescribed by the chair for such purpose, which may be electronic. (b) In addition, prior authorization for the following special services (PAR: Special Services) is required: (1) Lumbar fusion as set forth in E.4 of the New York Mid and Low Back Injury Medical Treatment Guidelines; (2) Artificial disc replacement as set forth in E.5 of the New York Mid and Low Back Injury Medical Treatment Guidelines, and in E.3 of the New York Neck Injury Medical Treatment Guidelines; (3) Vertebroplasty as set forth in E.6.a.i. of the New York Mid and Low Back Injury Medical Treatment Guidelines; (4) Kyphoplasty as set forth in E.6.a.i. of the New York Mid and Low Back Injury Medical Treatment Guidelines; (5) Electrical bone stimulation as set forth in the New York Mid and Low Back Injury Medical Treatment Guidelines and the New York Neck Injury Medical Treatment Guidelines; (6) Osteochondral autograft as set forth in D.1.f and Table 4 of the New York Knee Injury Medical Treatment Guidelines; (7) Autologous chondrocyte implantation as set forth in D.1.f., Table 5, and D.1.g. of the New York Knee Injury Medical Treatment Guidelines; (8) Meniscal allograft transplantation as set forth in D.6.f., Table 8, and D.7. of the New York Knee Injury Medical Treatment Guidelines; (9) Knee arthroplasty (total or partial knee joint replacement) as set forth in F.2. and Table 11 of the New York Knee Injury Medical Treatment Guidelines; (10) Spinal Cord Pain Stimulators as set forth in G.1 of the Non-Acute Pain Medical Treatment Guidelines; (11) Intrathecal Drug Delivery (Pain Pumps) as set forth in G.2 of the Non-Acute Pain Medical Treatment Guidelines ; (12) Sacroiliac joint (SIJ) fusion as set forth in E.8 of the Mid and Low Back Medical Treatment Guidelines; and (13) Peripheral Nerve Stimulation (PNS) as set forth in G.2 of the Non-Acute Pain Medical Treatment Guidelines. (c) Notwithstanding that a surgical procedure is consistent with the guidelines, a second or subsequent performance of such surgical procedure shall require a PAR: special services if it is repeated because of the failure or incomplete success of the same surgical procedure performed earlier, and if the medical treatment guidelines do not specifically address multiple procedures. (d) This section shall not apply to prior authorization requests from the formulary, as set forth in Part 441 of this chapter, or the durable medical equipment fee schedule, as set forth in Part 442 of this chapter. (a) When a treating medical provider determines that medical care that varies from the Medical Treatment Guidelines, such as when a treatment, procedure, or test is not recommended by the Medical Treatment Guidelines, appropriate for the claimant and medically necessary, he or she shall request a variance from the insurance carrier, self-insured employer, or third party administrator by submitting a prior approval request (PAR: MTG Variance) (hereinafter "PAR") in the format prescribed by the chair for such purpose, which may be electronic. (b) In addition, prior authorization for the following special services (PAR: Special Services) is required: (1) Lumbar fusion as set forth in E.4 of the New York Mid and Low Back Injury Medical Treatment Guidelines; (2) Artificial disc replacement as set forth in E.5 of the New York Mid and Low Back Injury Medical Treatment Guidelines, and in E.3 of the New York Neck Injury Medical Treatment Guidelines; (3) Vertebroplasty as set forth in E.6.a.i. of the New York Mid and Low Back Injury Medical Treatment Guidelines; (4) Kyphoplasty as set forth in E.6.a.i. of the New York Mid and Low Back Injury Medical Treatment Guidelines; (5) Electrical bone stimulation as set forth in the New York Mid and Low Back Injury Medical Treatment Guidelines and the New York Neck Injury Medical Treatment Guidelines; (6) Osteochondral autograft as set forth in D.1.f and Table 4 of the New York Knee Injury Medical Treatment Guidelines; (7) Autologous chondrocyte implantation as set forth in D.1.f., Table 5, and D.1.g. of the New York Knee Injury Medical Treatment Guidelines; (8) Meniscal allograft transplantation as set forth in D.6.f., Table 8, and D.7. of the New York Knee Injury Medical Treatment Guidelines; (9) Knee arthroplasty (total or partial knee joint replacement) as set forth in F.2. and Table 11 of the New York Knee Injury Medical Treatment Guidelines; (10) Spinal Cord Pain Stimulators as set forth in G.1 of the Non-Acute Pain Medical Treatment Guidelines; (11) Intrathecal Drug Delivery (Pain Pumps) as set forth in G.2 of the Non-Acute Pain Medical Treatment Guidelines ; (12) Sacroiliac joint (SIJ) fusion as set forth in E.8 of the Mid and Low Back Medical Treatment Guidelines; and (13) Peripheral Nerve Stimulation (PNS) as set forth in G.2 of the Non-Acute Pain Medical Treatment Guidelines. (1) Lumbar fusion as set forth in E.4 of the New York Mid and Low Back Injury Medical Treatment Guidelines; (2) Artificial disc replacement as set forth in E.5 of the New York Mid and Low Back Injury Medical Treatment Guidelines, and in E.3 of the New York Neck Injury Medical Treatment Guidelines; (3) Vertebroplasty as set forth in E.6.a.i. of the New York Mid and Low Back Injury Medical Treatment Guidelines; (4) Kyphoplasty as set forth in E.6.a.i. of the New York Mid and Low Back Injury Medical Treatment Guidelines; (5) Electrical bone stimulation as set forth in the New York Mid and Low Back Injury Medical Treatment Guidelines and the New York Neck Injury Medical Treatment Guidelines; (6) Osteochondral autograft as set forth in D.1.f and Table 4 of the New York Knee Injury Medical Treatment Guidelines; (7) Autologous chondrocyte implantation as set forth in D.1.f., Table 5, and D.1.g. of the New York Knee Injury Medical Treatment Guidelines; (8) Meniscal allograft transplantation as set forth in D.6.f., Table 8, and D.7. of the New York Knee Injury Medical Treatment Guidelines; (9) Knee arthroplasty (total or partial knee joint replacement) as set forth in F.2. and Table 11 of the New York Knee Injury Medical Treatment Guidelines; (10) Spinal Cord Pain Stimulators as set forth in G.1 of the Non-Acute Pain Medical Treatment Guidelines; (11) Intrathecal Drug Delivery (Pain Pumps) as set forth in G.2 of the Non-Acute Pain Medical Treatment Guidelines ; (12) Sacroiliac joint (SIJ) fusion as set forth in E.8 of the Mid and Low Back Medical Treatment Guidelines; and (13) Peripheral Nerve Stimulation (PNS) as set forth in G.2 of the Non-Acute Pain Medical Treatment Guidelines. (c) Notwithstanding that a surgical procedure is consistent with the guidelines, a second or subsequent performance of such surgical procedure shall require a PAR: special services if it is repeated because of the failure or incomplete success of the same surgical procedure performed earlier, and if the medical treatment guidelines do not specifically address multiple procedures. (d) This section shall not apply to prior authorization requests from the formulary, as set forth in Part 441 of this chapter, or the durable medical equipment fee schedule, as set forth in Part 442 of this chapter. (ii) A PAR must be requested and granted by the carrier, selfinsured employer, or third-party administrator, the Board or order of the Chair before medical care that varies from the Medical Treatment Guidelines or special service is provided to the claimant and the carrier, self-insured employer, or third-party administrator may deny the PAR and deny payment of the treatment requested if the treatment is rendered prior to the PAR being granted by the carrier, self-insured employer, third-party administrator, the Board or order of the Chair. (iii) For the purposes of this section, a treating medical provider shall not include a physician assistant, acupuncturist, physical therapist, or occupational therapist, as defined in section 13-b. (b) Insurance carriers, self-insured employers, and third-party administrators. (1) Insurance carriers, self-insured employers, or third-party administrators shall provide the Chair or his or her designee in the manner prescribed by the Chair with the name and contact information for the point(s) of contact for PAR review. Such contact information may include the contacts' direct telephone number(s) and email address(es). (i) If the designated point(s) of contact changes at any time for any reason, the insurance carrier, self-insured employer, or third-party administrator shall notify the Chair or his or her designee of such change in the manner prescribed by the Chair. (ii) The list of designated points of contact for each insurance carrier, self-insured employer, or third-party administrator shall be maintained by the Board electronically. When a treating medical provider submits a PAR electronically, it shall be directed to the appropriate contact person. Any change in the designated contact shall not be effective until the designated contact information has been updated in the Board's electronic records. (iii) In the event that a carrier, self-insured employer, or third-party administrator fails to so provide the Chair or his or her designee with such name and contact information (in the manner prescribed), or provides incorrect or incomplete contact information during initial registration or when updating pursuant to paragraph (1) of this subdivision, such carrier may be subject to: (a) Orders of the Chair granting any PAR submitted during such time when the name and contact information is missing, incomplete or incorrect; and (b) Penalties issued pursuant to section 114-a (3) of the Workers' Compensation Law for every case, where a PAR was submitted. (2) Review by insurance carrier, self-insured employer, or third-party administrator. When an insurance carrier, self-insured employer, or third-party administrator denies or partially approves a PAR, the insurance carrier, self-insured employer, or third-party administrator must also assert any other basis for denial or such basis for denial will be deemed waived. Except as set forth in subdivision (b) below, all denials or partial approvals must be made by the Carrier's Physician. A partial approval limits the length of time or frequency of the treatment, or authorizes a related but different treatment than that requested in the PAR. (i) Without IME or review of records. (a) The insurance carrier, self-insured employer, or third party administrator shall review the PAR and respond to the request in the format prescribed by the chair within 15 calendar days of receipt, except as provided in subparagraph (ii) of this paragraph. Receipt is deemed to be the date submitted. (1) In the event the PAR is submitted after the mandatory first report of injury pursuant to section 300.22(b) of this Chapter shall become due and no such report has been filed, the Board may issue an Order of the Chair granting the requested treatment. (b) In the following circumstances a PAR may be denied without an opinion by the Carrier's Physician or an IME or review of records. (1) If the PAR was submitted after the medical care was rendered, a medical opinion by the Carrier's Physician, a review of records, or independent medical examination is not required and the insurance carrier, self-insured employer or third party administrator may deny the PAR on the basis that it was not requested before the medical care was provided. (2) The insurance carrier, self-insured employer, or third-party administrator may deny a PAR on the basis that: (i) the treating medical provider seeks a PAR for a treatment, procedure or test that is substantially similar to a prior request from the treating medical provider that has not yet been denied by the carrier, self-insured employer or third party administrator; or (ii) that a prior substantially similar request has been denied, and the subsequent request does not contain any additional documentation or justification to the previous request. The carrier self-insured employer or third-party administrator may deny the PAR by specifying the basis for the denial. The carrier self-insured employer or third-party administrator may submit the denial without a medical opinion by Carrier's Physician's or independent medical examination. (3) If a case is closed, disallowed or cancelled, where ongoing medical treatment is resolved by an agreement pursuant to section 32 of the Workers' Compensation Law, subject to an offset pursuant to an approved third-party settlement in accordance with section 29 of the Workers' Compensation Law, or controverted in accordance with section 300.22(b)(1)(ii) or (c)(1) of this Chapter, or when a claimant fails to appear for a scheduled IME as set forth in (b)(ii)(2) herein, the insurance carrier, self-insured employer or third-party administrator may deny a PAR without review by the Carrier's Physician, or an independent medical examination. (i) Nothing herein shall prohibit a carrier from seeking review of a PAR by a Carrier's Physician or independent medical examiner. (ii) When a PAR is denied without review by Carrier's Physician in accordance with subdivision (b) herein, there shall be no review by the Medical Director's Office. A claimant may request review by the Board by filing a Request for Further Action, that demonstrates that the basis for denial is factually inaccurate. The Board may respond to such requests for review by letter or by referral to adjudication, as appropriate in the discretion of the Chair or his or her designee. (c) A denial or partial approval of the request for a variance for reasons other than those set forth in clause (a) of this subparagraph, including a denial for failure of the medical provider to meet the burden of proof that the PAR was appropriate for the claimant and medically necessary, or an approval that concedes medical necessity but does not affirm that the approved medical care will be paid at the fee schedule rate, must be reviewed by the Carrier's Physician, if an independent medical examination or review of records is not conducted as set forth in this paragraph. A denial or partial approval issued by other than a Carrier's Physician is not valid and may be deemed approved by the Board. Invalid denials may be subject to penalties pursuant to sections 13-a (6)(a) and 114-a (3) of the Workers' Compensation Law. (d) The carrier, self-insured employer or third-party administrator shall send the claimant notice of the approval, partial approval or denial of the PAR. Failure to send the claimant such notice may result in penalties under section 25(3)(e), for failure to file a required report with the Board, and section 13-a (6)(a) of the Workers' Compensation Law (ii) Review with IME or review of records. (a) If the insurance carrier, self-insured employer, or third party administrator wants an independent medical examination conducted of the claimant or a review of records in order to respond to the variance request, it shall provide notification of this decision in the format prescribed by the Chair which may be electronic within five business days of receipt of the PAR. A final response to the PAR shall be submitted in the format prescribed by the Chair which may be electronic within 30 calendar days of receipt of the request. (b) If the claimant fails to appear without reasonable cause for an independent medical examination scheduled by the insurance carrier, self-insured employer or third-party administrator in order to respond to a PAR, the request for a variance shall be denied. The insurance carrier, self-insured employer or third-party administrator shall submit the response to the PAR within 30 calendar days of receipt of the request. Receipt is determined as provided in clause (a) of this subparagraph. If the claimant requests review of the denial of the PAR based on his or her failure to appear, such request for review shall be reviewed by the Board in the manner prescribed by the Chair. Such request for review of the denial of the PAR shall be submitted in the manner prescribed by the Chair within 21 business days of receipt of the insurance carrier, self-insured employer or third-party administrator 's denial by the claimant. If the claimant requests review of the denial of the PAR and it is determined that the failure to appear was for reasonable grounds, the insurance carrier, self-insured employer or third party administrator will have 30 calendar days from the date of the filing of the decision to obtain an independent medical examination or 15 calendar days if proceeding in accordance with paragraph (i) herein, and provide a further response to the response to PAR. (3) Insurance carrier, Self-insured employer or Third party administrator, response to PAR. (i) The PAR response shall be in the format prescribed by the Chair and shall clearly state whether the PAR has been granted, denied, granted with respect to medical necessity but liability for payment is withheld, or partially granted. If a PAR has been partially granted, the response shall specify the medical treatment, procedure or test that has been granted. (ii) If the insurance carrier, self-insured employer or third party administrator denies a PAR, it shall state the basis for the denial in detail and, if for reasons other than those set forth in clause (2)(i)(b) or (c) or (2)(ii)(b) of this subdivision, submit with its response the written report of the Carrier's Physician that reviewed the PAR. When the denial is based on an independent medical examination, the denial shall identify the independent medical examination report or review of records report, if already submitted to the Board, by the document identification number in the electronic case folder and date received by the Board. The insurance carrier, self-insured employer or third-party administrator may submit citations or copies of relevant literature published in recognized, peer-reviewed medical journals in support of a denial of a PAR. If the insurance carrier, self-insured employer or third-party administrator concedes the medical necessity of the medical care, it may grant without liability, only if the case has been controverted in accordance with section 300.22(b)(1)(ii) or (c)(1) of this Chapter, or the medical care is for a body part or condition that has not been accepted by the insurance carrier, self-insured employer or third-party administrator or established by the Board. (iii) When a PAR is denied without review by Carrier's Physician in accordance with subdivision (b) herein, there shall be no review by the Medical Director's Office. A claimant may request review by the Board by filing a Request for Further Action, that demonstrates that the basis for denial is factually inaccurate. The Board may respond to such requests for review by letter or by referral to adjudication, as appropriate in the discretion of the Chair or his or her designee. (4) If a claim is controverted or the time to controvert the claim has not expired, and the insurance carrier, self-insured employer, or third party administrator grants or partially grants a PAR, such grant is limited to the question of appropriateness for the claimant and medical necessity, and it shall not be construed as an admission that the condition for which the PAR is requested is compensable and the insurance carrier, self-insured employer or third party administrator is not liable for the cost of such treatment unless the claim or condition is established. (5) Unless the insurance carrier, self-insured employer, or third-party administrator has properly denied or granted as to medical necessity but withheld liability for the claim, the carrier may not thereafter object to payment for such medical care at the fee schedule rate and any such objections will be rejected by the Board and applicable penalties imposed. (1) Insurance carriers, self-insured employers, or third-party administrators shall provide the Chair or his or her designee in the manner prescribed by the Chair with the name and contact information for the point(s) of contact for PAR review. Such contact information may include the contacts' direct telephone number(s) and email address(es). (i) If the designated point(s) of contact changes at any time for any reason, the insurance carrier, self-insured employer, or third-party administrator shall notify the Chair or his or her designee of such change in the manner prescribed by the Chair. (ii) The list of designated points of contact for each insurance carrier, self-insured employer, or third-party administrator shall be maintained by the Board electronically. When a treating medical provider submits a PAR electronically, it shall be directed to the appropriate contact person. Any change in the designated contact shall not be effective until the designated contact information has been updated in the Board's electronic records. (iii) In the event that a carrier, self-insured employer, or third-party administrator fails to so provide the Chair or his or her designee with such name and contact information (in the manner prescribed), or provides incorrect or incomplete contact information during initial registration or when updating pursuant to paragraph (1) of this subdivision, such carrier may be subject to: (a) Orders of the Chair granting any PAR submitted during such time when the name and contact information is missing, incomplete or incorrect; and (b) Penalties issued pursuant to section 114-a (3) of the Workers' Compensation Law for every case, where a PAR was submitted. (i) If the designated point(s) of contact changes at any time for any reason, the insurance carrier, self-insured employer, or third-party administrator shall notify the Chair or his or her designee of such change in the manner prescribed by the Chair. (ii) The list of designated points of contact for each insurance carrier, self-insured employer, or third-party administrator shall be maintained by the Board electronically. When a treating medical provider submits a PAR electronically, it shall be directed to the appropriate contact person. Any change in the designated contact shall not be effective until the designated contact information has been updated in the Board's electronic records. (iii) In the event that a carrier, self-insured employer, or third-party administrator fails to so provide the Chair or his or her designee with such name and contact information (in the manner prescribed), or provides incorrect or incomplete contact information during initial registration or when updating pursuant to paragraph (1) of this subdivision, such carrier may be subject to: (a) Orders of the Chair granting any PAR submitted during such time when the name and contact information is missing, incomplete or incorrect; and (b) Penalties issued pursuant to section 114-a (3) of the Workers' Compensation Law for every case, where a PAR was submitted. (a) Orders of the Chair granting any PAR submitted during such time when the name and contact information is missing, incomplete or incorrect; and (b) Penalties issued pursuant to section 114-a (3) of the Workers' Compensation Law for every case, where a PAR was submitted. (2) Review by insurance carrier, self-insured employer, or third-party administrator. When an insurance carrier, self-insured employer, or third-party administrator denies or partially approves a PAR, the insurance carrier, self-insured employer, or third-party administrator must also assert any other basis for denial or such basis for denial will be deemed waived. Except as set forth in subdivision (b) below, all denials or partial approvals must be made by the Carrier's Physician. A partial approval limits the length of time or frequency of the treatment, or authorizes a related but different treatment than that requested in the PAR. (i) Without IME or review of records. (a) The insurance carrier, self-insured employer, or third party administrator shall review the PAR and respond to the request in the format prescribed by the chair within 15 calendar days of receipt, except as provided in subparagraph (ii) of this paragraph. Receipt is deemed to be the date submitted. (1) In the event the PAR is submitted after the mandatory first report of injury pursuant to section 300.22(b) of this Chapter shall become due and no such report has been filed, the Board may issue an Order of the Chair granting the requested treatment. (b) In the following circumstances a PAR may be denied without an opinion by the Carrier's Physician or an IME or review of records. (1) If the PAR was submitted after the medical care was rendered, a medical opinion by the Carrier's Physician, a review of records, or independent medical examination is not required and the insurance carrier, self-insured employer or third party administrator may deny the PAR on the basis that it was not requested before the medical care was provided. (2) The insurance carrier, self-insured employer, or third-party administrator may deny a PAR on the basis that: (i) the treating medical provider seeks a PAR for a treatment, procedure or test that is substantially similar to a prior request from the treating medical provider that has not yet been denied by the carrier, self-insured employer or third party administrator; or (ii) that a prior substantially similar request has been denied, and the subsequent request does not contain any additional documentation or justification to the previous request. The carrier self-insured employer or third-party administrator may deny the PAR by specifying the basis for the denial. The carrier self-insured employer or third-party administrator may submit the denial without a medical opinion by Carrier's Physician's or independent medical examination. (3) If a case is closed, disallowed or cancelled, where ongoing medical treatment is resolved by an agreement pursuant to section 32 of the Workers' Compensation Law, subject to an offset pursuant to an approved third-party settlement in accordance with section 29 of the Workers' Compensation Law, or controverted in accordance with section 300.22(b)(1)(ii) or (c)(1) of this Chapter, or when a claimant fails to appear for a scheduled IME as set forth in (b)(ii)(2) herein, the insurance carrier, self-insured employer or third-party administrator may deny a PAR without review by the Carrier's Physician, or an independent medical examination. (i) Nothing herein shall prohibit a carrier from seeking review of a PAR by a Carrier's Physician or independent medical examiner. (ii) When a PAR is denied without review by Carrier's Physician in accordance with subdivision (b) herein, there shall be no review by the Medical Director's Office. A claimant may request review by the Board by filing a Request for Further Action, that demonstrates that the basis for denial is factually inaccurate. The Board may respond to such requests for review by letter or by referral to adjudication, as appropriate in the discretion of the Chair or his or her designee. (c) A denial or partial approval of the request for a variance for reasons other than those set forth in clause (a) of this subparagraph, including a denial for failure of the medical provider to meet the burden of proof that the PAR was appropriate for the claimant and medically necessary, or an approval that concedes medical necessity but does not affirm that the approved medical care will be paid at the fee schedule rate, must be reviewed by the Carrier's Physician, if an independent medical examination or review of records is not conducted as set forth in this paragraph. A denial or partial approval issued by other than a Carrier's Physician is not valid and may be deemed approved by the Board. Invalid denials may be subject to penalties pursuant to sections 13-a (6)(a) and 114-a (3) of the Workers' Compensation Law. (d) The carrier, self-insured employer or third-party administrator shall send the claimant notice of the approval, partial approval or denial of the PAR. Failure to send the claimant such notice may result in penalties under section 25(3)(e), for failure to file a required report with the Board, and section 13-a (6)(a) of the Workers' Compensation Law (ii) Review with IME or review of records. (a) If the insurance carrier, self-insured employer, or third party administrator wants an independent medical examination conducted of the claimant or a review of records in order to respond to the variance request, it shall provide notification of this decision in the format prescribed by the Chair which may be electronic within five business days of receipt of the PAR. A final response to the PAR shall be submitted in the format prescribed by the Chair which may be electronic within 30 calendar days of receipt of the request. (b) If the claimant fails to appear without reasonable cause for an independent medical examination scheduled by the insurance carrier, self-insured employer or third-party administrator in order to respond to a PAR, the request for a variance shall be denied. The insurance carrier, self-insured employer or third-party administrator shall submit the response to the PAR within 30 calendar days of receipt of the request. Receipt is determined as provided in clause (a) of this subparagraph. If the claimant requests review of the denial of the PAR based on his or her failure to appear, such request for review shall be reviewed by the Board in the manner prescribed by the Chair. Such request for review of the denial of the PAR shall be submitted in the manner prescribed by the Chair within 21 business days of receipt of the insurance carrier, self-insured employer or third-party administrator 's denial by the claimant. If the claimant requests review of the denial of the PAR and it is determined that the failure to appear was for reasonable grounds, the insurance carrier, self-insured employer or third party administrator will have 30 calendar days from the date of the filing of the decision to obtain an independent medical examination or 15 calendar days if proceeding in accordance with paragraph (i) herein, and provide a further response to the response to PAR. (i) Without IME or review of records. (a) The insurance carrier, self-insured employer, or third party administrator shall review the PAR and respond to the request in the format prescribed by the chair within 15 calendar days of receipt, except as provided in subparagraph (ii) of this paragraph. Receipt is deemed to be the date submitted. (1) In the event the PAR is submitted after the mandatory first report of injury pursuant to section 300.22(b) of this Chapter shall become due and no such report has been filed, the Board may issue an Order of the Chair granting the requested treatment. (b) In the following circumstances a PAR may be denied without an opinion by the Carrier's Physician or an IME or review of records. (1) If the PAR was submitted after the medical care was rendered, a medical opinion by the Carrier's Physician, a review of records, or independent medical examination is not required and the insurance carrier, self-insured employer or third party administrator may deny the PAR on the basis that it was not requested before the medical care was provided. (2) The insurance carrier, self-insured employer, or third-party administrator may deny a PAR on the basis that: (i) the treating medical provider seeks a PAR for a treatment, procedure or test that is substantially similar to a prior request from the treating medical provider that has not yet been denied by the carrier, self-insured employer or third party administrator; or (ii) that a prior substantially similar request has been denied, and the subsequent request does not contain any additional documentation or justification to the previous request. The carrier self-insured employer or third-party administrator may deny the PAR by specifying the basis for the denial. The carrier self-insured employer or third-party administrator may submit the denial without a medical opinion by Carrier's Physician's or independent medical examination. (3) If a case is closed, disallowed or cancelled, where ongoing medical treatment is resolved by an agreement pursuant to section 32 of the Workers' Compensation Law, subject to an offset pursuant to an approved third-party settlement in accordance with section 29 of the Workers' Compensation Law, or controverted in accordance with section 300.22(b)(1)(ii) or (c)(1) of this Chapter, or when a claimant fails to appear for a scheduled IME as set forth in (b)(ii)(2) herein, the insurance carrier, self-insured employer or third-party administrator may deny a PAR without review by the Carrier's Physician, or an independent medical examination. (i) Nothing herein shall prohibit a carrier from seeking review of a PAR by a Carrier's Physician or independent medical examiner. (ii) When a PAR is denied without review by Carrier's Physician in accordance with subdivision (b) herein, there shall be no review by the Medical Director's Office. A claimant may request review by the Board by filing a Request for Further Action, that demonstrates that the basis for denial is factually inaccurate. The Board may respond to such requests for review by letter or by referral to adjudication, as appropriate in the discretion of the Chair or his or her designee. (c) A denial or partial approval of the request for a variance for reasons other than those set forth in clause (a) of this subparagraph, including a denial for failure of the medical provider to meet the burden of proof that the PAR was appropriate for the claimant and medically necessary, or an approval that concedes medical necessity but does not affirm that the approved medical care will be paid at the fee schedule rate, must be reviewed by the Carrier's Physician, if an independent medical examination or review of records is not conducted as set forth in this paragraph. A denial or partial approval issued by other than a Carrier's Physician is not valid and may be deemed approved by the Board. Invalid denials may be subject to penalties pursuant to sections 13-a (6)(a) and 114-a (3) of the Workers' Compensation Law. (d) The carrier, self-insured employer or third-party administrator shall send the claimant notice of the approval, partial approval or denial of the PAR. Failure to send the claimant such notice may result in penalties under section 25(3)(e), for failure to file a required report with the Board, and section 13-a (6)(a) of the Workers' Compensation Law (a) The insurance carrier, self-insured employer, or third party administrator shall review the PAR and respond to the request in the format prescribed by the chair within 15 calendar days of receipt, except as provided in subparagraph (ii) of this paragraph. Receipt is deemed to be the date submitted. (1) In the event the PAR is submitted after the mandatory first report of injury pursuant to section 300.22(b) of this Chapter shall become due and no such report has been filed, the Board may issue an Order of the Chair granting the requested treatment. (1) In the event the PAR is submitted after the mandatory first report of injury pursuant to section 300.22(b) of this Chapter shall become due and no such report has been filed, the Board may issue an Order of the Chair granting the requested treatment. (b) In the following circumstances a PAR may be denied without an opinion by the Carrier's Physician or an IME or review of records. (1) If the PAR was submitted after the medical care was rendered, a medical opinion by the Carrier's Physician, a review of records, or independent medical examination is not required and the insurance carrier, self-insured employer or third party administrator may deny the PAR on the basis that it was not requested before the medical care was provided. (2) The insurance carrier, self-insured employer, or third-party administrator may deny a PAR on the basis that: (i) the treating medical provider seeks a PAR for a treatment, procedure or test that is substantially similar to a prior request from the treating medical provider that has not yet been denied by the carrier, self-insured employer or third party administrator; or (ii) that a prior substantially similar request has been denied, and the subsequent request does not contain any additional documentation or justification to the previous request. The carrier self-insured employer or third-party administrator may deny the PAR by specifying the basis for the denial. The carrier self-insured employer or third-party administrator may submit the denial without a medical opinion by Carrier's Physician's or independent medical examination. (3) If a case is closed, disallowed or cancelled, where ongoing medical treatment is resolved by an agreement pursuant to section 32 of the Workers' Compensation Law, subject to an offset pursuant to an approved third-party settlement in accordance with section 29 of the Workers' Compensation Law, or controverted in accordance with section 300.22(b)(1)(ii) or (c)(1) of this Chapter, or when a claimant fails to appear for a scheduled IME as set forth in (b)(ii)(2) herein, the insurance carrier, self-insured employer or third-party administrator may deny a PAR without review by the Carrier's Physician, or an independent medical examination. (i) Nothing herein shall prohibit a carrier from seeking review of a PAR by a Carrier's Physician or independent medical examiner. (ii) When a PAR is denied without review by Carrier's Physician in accordance with subdivision (b) herein, there shall be no review by the Medical Director's Office. A claimant may request review by the Board by filing a Request for Further Action, that demonstrates that the basis for denial is factually inaccurate. The Board may respond to such requests for review by letter or by referral to adjudication, as appropriate in the discretion of the Chair or his or her designee. (1) If the PAR was submitted after the medical care was rendered, a medical opinion by the Carrier's Physician, a review of records, or independent medical examination is not required and the insurance carrier, self-insured employer or third party administrator may deny the PAR on the basis that it was not requested before the medical care was provided. (2) The insurance carrier, self-insured employer, or third-party administrator may deny a PAR on the basis that: (i) the treating medical provider seeks a PAR for a treatment, procedure or test that is substantially similar to a prior request from the treating medical provider that has not yet been denied by the carrier, self-insured employer or third party administrator; or (ii) that a prior substantially similar request has been denied, and the subsequent request does not contain any additional documentation or justification to the previous request. The carrier self-insured employer or third-party administrator may deny the PAR by specifying the basis for the denial. The carrier self-insured employer or third-party administrator may submit the denial without a medical opinion by Carrier's Physician's or independent medical examination. (i) the treating medical provider seeks a PAR for a treatment, procedure or test that is substantially similar to a prior request from the treating medical provider that has not yet been denied by the carrier, self-insured employer or third party administrator; or (ii) that a prior substantially similar request has been denied, and the subsequent request does not contain any additional documentation or justification to the previous request. The carrier self-insured employer or third-party administrator may deny the PAR by specifying the basis for the denial. The carrier self-insured employer or third-party administrator may submit the denial without a medical opinion by Carrier's Physician's or independent medical examination. (3) If a case is closed, disallowed or cancelled, where ongoing medical treatment is resolved by an agreement pursuant to section 32 of the Workers' Compensation Law, subject to an offset pursuant to an approved third-party settlement in accordance with section 29 of the Workers' Compensation Law, or controverted in accordance with section 300.22(b)(1)(ii) or (c)(1) of this Chapter, or when a claimant fails to appear for a scheduled IME as set forth in (b)(ii)(2) herein, the insurance carrier, self-insured employer or third-party administrator may deny a PAR without review by the Carrier's Physician, or an independent medical examination. (i) Nothing herein shall prohibit a carrier from seeking review of a PAR by a Carrier's Physician or independent medical examiner. (ii) When a PAR is denied without review by Carrier's Physician in accordance with subdivision (b) herein, there shall be no review by the Medical Director's Office. A claimant may request review by the Board by filing a Request for Further Action, that demonstrates that the basis for denial is factually inaccurate. The Board may respond to such requests for review by letter or by referral to adjudication, as appropriate in the discretion of the Chair or his or her designee. (i) Nothing herein shall prohibit a carrier from seeking review of a PAR by a Carrier's Physician or independent medical examiner. (ii) When a PAR is denied without review by Carrier's Physician in accordance with subdivision (b) herein, there shall be no review by the Medical Director's Office. A claimant may request review by the Board by filing a Request for Further Action, that demonstrates that the basis for denial is factually inaccurate. The Board may respond to such requests for review by letter or by referral to adjudication, as appropriate in the discretion of the Chair or his or her designee. (c) A denial or partial approval of the request for a variance for reasons other than those set forth in clause (a) of this subparagraph, including a denial for failure of the medical provider to meet the burden of proof that the PAR was appropriate for the claimant and medically necessary, or an approval that concedes medical necessity but does not affirm that the approved medical care will be paid at the fee schedule rate, must be reviewed by the Carrier's Physician, if an independent medical examination or review of records is not conducted as set forth in this paragraph. A denial or partial approval issued by other than a Carrier's Physician is not valid and may be deemed approved by the Board. Invalid denials may be subject to penalties pursuant to sections 13-a (6)(a) and 114-a (3) of the Workers' Compensation Law. (d) The carrier, self-insured employer or third-party administrator shall send the claimant notice of the approval, partial approval or denial of the PAR. Failure to send the claimant such notice may result in penalties under section 25(3)(e), for failure to file a required report with the Board, and section 13-a (6)(a) of the Workers' Compensation Law (ii) Review with IME or review of records. (a) If the insurance carrier, self-insured employer, or third party administrator wants an independent medical examination conducted of the claimant or a review of records in order to respond to the variance request, it shall provide notification of this decision in the format prescribed by the Chair which may be electronic within five business days of receipt of the PAR. A final response to the PAR shall be submitted in the format prescribed by the Chair which may be electronic within 30 calendar days of receipt of the request. (b) If the claimant fails to appear without reasonable cause for an independent medical examination scheduled by the insurance carrier, self-insured employer or third-party administrator in order to respond to a PAR, the request for a variance shall be denied. The insurance carrier, self-insured employer or third-party administrator shall submit the response to the PAR within 30 calendar days of receipt of the request. Receipt is determined as provided in clause (a) of this subparagraph. If the claimant requests review of the denial of the PAR based on his or her failure to appear, such request for review shall be reviewed by the Board in the manner prescribed by the Chair. Such request for review of the denial of the PAR shall be submitted in the manner prescribed by the Chair within 21 business days of receipt of the insurance carrier, self-insured employer or third-party administrator 's denial by the claimant. If the claimant requests review of the denial of the PAR and it is determined that the failure to appear was for reasonable grounds, the insurance carrier, self-insured employer or third party administrator will have 30 calendar days from the date of the filing of the decision to obtain an independent medical examination or 15 calendar days if proceeding in accordance with paragraph (i) herein, and provide a further response to the response to PAR. (a) If the insurance carrier, self-insured employer, or third party administrator wants an independent medical examination conducted of the claimant or a review of records in order to respond to the variance request, it shall provide notification of this decision in the format prescribed by the Chair which may be electronic within five business days of receipt of the PAR. A final response to the PAR shall be submitted in the format prescribed by the Chair which may be electronic within 30 calendar days of receipt of the request. (b) If the claimant fails to appear without reasonable cause for an independent medical examination scheduled by the insurance carrier, self-insured employer or third-party administrator in order to respond to a PAR, the request for a variance shall be denied. The insurance carrier, self-insured employer or third-party administrator shall submit the response to the PAR within 30 calendar days of receipt of the request. Receipt is determined as provided in clause (a) of this subparagraph. If the claimant requests review of the denial of the PAR based on his or her failure to appear, such request for review shall be reviewed by the Board in the manner prescribed by the Chair. Such request for review of the denial of the PAR shall be submitted in the manner prescribed by the Chair within 21 business days of receipt of the insurance carrier, self-insured employer or third-party administrator 's denial by the claimant. If the claimant requests review of the denial of the PAR and it is determined that the failure to appear was for reasonable grounds, the insurance carrier, self-insured employer or third party administrator will have 30 calendar days from the date of the filing of the decision to obtain an independent medical examination or 15 calendar days if proceeding in accordance with paragraph (i) herein, and provide a further response to the response to PAR. (3) Insurance carrier, Self-insured employer or Third party administrator, response to PAR. (i) The PAR response shall be in the format prescribed by the Chair and shall clearly state whether the PAR has been granted, denied, granted with respect to medical necessity but liability for payment is withheld, or partially granted. If a PAR has been partially granted, the response shall specify the medical treatment, procedure or test that has been granted. (ii) If the insurance carrier, self-insured employer or third party administrator denies a PAR, it shall state the basis for the denial in detail and, if for reasons other than those set forth in clause (2)(i)(b) or (c) or (2)(ii)(b) of this subdivision, submit with its response the written report of the Carrier's Physician that reviewed the PAR. When the denial is based on an independent medical examination, the denial shall identify the independent medical examination report or review of records report, if already submitted to the Board, by the document identification number in the electronic case folder and date received by the Board. The insurance carrier, self-insured employer or third-party administrator may submit citations or copies of relevant literature published in recognized, peer-reviewed medical journals in support of a denial of a PAR. If the insurance carrier, self-insured employer or third-party administrator concedes the medical necessity of the medical care, it may grant without liability, only if the case has been controverted in accordance with section 300.22(b)(1)(ii) or (c)(1) of this Chapter, or the medical care is for a body part or condition that has not been accepted by the insurance carrier, self-insured employer or third-party administrator or established by the Board. (iii) When a PAR is denied without review by Carrier's Physician in accordance with subdivision (b) herein, there shall be no review by the Medical Director's Office. A claimant may request review by the Board by filing a Request for Further Action, that demonstrates that the basis for denial is factually inaccurate. The Board may respond to such requests for review by letter or by referral to adjudication, as appropriate in the discretion of the Chair or his or her designee. (i) The PAR response shall be in the format prescribed by the Chair and shall clearly state whether the PAR has been granted, denied, granted with respect to medical necessity but liability for payment is withheld, or partially granted. If a PAR has been partially granted, the response shall specify the medical treatment, procedure or test that has been granted. (ii) If the insurance carrier, self-insured employer or third party administrator denies a PAR, it shall state the basis for the denial in detail and, if for reasons other than those set forth in clause (2)(i)(b) or (c) or (2)(ii)(b) of this subdivision, submit with its response the written report of the Carrier's Physician that reviewed the PAR. When the denial is based on an independent medical examination, the denial shall identify the independent medical examination report or review of records report, if already submitted to the Board, by the document identification number in the electronic case folder and date received by the Board. The insurance carrier, self-insured employer or third-party administrator may submit citations or copies of relevant literature published in recognized, peer-reviewed medical journals in support of a denial of a PAR. If the insurance carrier, self-insured employer or third-party administrator concedes the medical necessity of the medical care, it may grant without liability, only if the case has been controverted in accordance with section 300.22(b)(1)(ii) or (c)(1) of this Chapter, or the medical care is for a body part or condition that has not been accepted by the insurance carrier, self-insured employer or third-party administrator or established by the Board. (iii) When a PAR is denied without review by Carrier's Physician in accordance with subdivision (b) herein, there shall be no review by the Medical Director's Office. A claimant may request review by the Board by filing a Request for Further Action, that demonstrates that the basis for denial is factually inaccurate. The Board may respond to such requests for review by letter or by referral to adjudication, as appropriate in the discretion of the Chair or his or her designee. (4) If a claim is controverted or the time to controvert the claim has not expired, and the insurance carrier, self-insured employer, or third party administrator grants or partially grants a PAR, such grant is limited to the question of appropriateness for the claimant and medical necessity, and it shall not be construed as an admission that the condition for which the PAR is requested is compensable and the insurance carrier, self-insured employer or third party administrator is not liable for the cost of such treatment unless the claim or condition is established. (5) Unless the insurance carrier, self-insured employer, or third-party administrator has properly denied or granted as to medical necessity but withheld liability for the claim, the carrier may not thereafter object to payment for such medical care at the fee schedule rate and any such objections will be rejected by the Board and applicable penalties imposed. (c) Request for review of denial of a PAR. Upon receipt of the denial of a PAR by Carrier's Physician or by an Independent Medical Examination, the treating medical provider may request review of the denial by the Medical Director's Office as set forth in subdivision (d) herein. A request for review of the denial of the PAR shall be submitted within 10 calendar days of the insurance carrier, self-insured employer or third-party administrator 's denial. The request shall be made in the format prescribed by the Chair and provide all information requested. When a denial is not based on a claimant's failure to appear for an independent medical examination pursuant to subparagraph (2)(ii)(b) of this section and the treating medical provider seeks review of such denial, the treating medical provider may request review of the PAR denial through the process set forth in paragraph (d) of this section. If the request is not received by the Board within 10 calendar days of receipt of the denial, the denial of the PAR will be deemed final. A claimant may request review of a denial of a PAR by an independent medical examination in accordance with paragraph (d)(3) herein. (d) Process for requesting review of denial of PARs except denials based on the claimant's failure to appear for an IME. 1. All requests for review of denials or partial approvals of a PAR by a Carrier's Physician shall be submitted to the Medical Director's Office in the format prescribed by the Chair. 2. When a denial is based on a reason set forth in (b)(2)(i)(b), in addition to a Carrier's Physician review, the request for review shall be submitted to the Medical Director's Office. 3. When a denial or partial approval is based upon an independent medical examination, the medical provider may request review by the Medical Director's Office unless a request for further action through adjudication is filed by the claimant. In the event a decision is rendered by the Medical Director's Office, the claimant retains the rights set forth in subparagraph (7) herein. 4. The Chair or Medical Director may designate private entities to evaluate such requests for review of denials by the carrier's physician provided that the entity has: i. the appropriate URAC accreditation or such accreditation/certification as designated by the Chair, ii. other demonstrated expertise and criteria established by the Board; and iii. no conflict of interest exists in resolving the subject dispute. 5. When a medical provider wishes to request review of a denial or partial approval of a PAR, the medical provider shall submit the request to the Medical Director's Office in the format prescribed by the Chair within 10 calendar days of the denial date together with all documentation submitted in support of its initial request, and the denial or partial approval issued following request. 6. A decision by the Medical Director's Office (or designated accredited entity) is final and binding on the medical provider, and upon the carrier for issues related to medical necessity. Such decision shall be binding and not appealable under Workers' Compensation Law section 23. 7. Notwithstanding paragraph (5) and (6) herein, a claimant may request review of a Medical Director's Office decision or a denial by Carrier's Physician by filing a Request for Further Action that demonstrates that such treatment is medically necessary. A Request for Further Action following denial by a Carrier's Physician shall render a request for review by the Medical Provider to the Medical Director's Office moot. Decision on the denial will be made in Adjudication. The Board may respond to such requests for review by letter or by referral to adjudication, including the expedited hearing process, as appropriate in the discretion of the Chair or his or her designee. 8. If the insurance carrier, self-insured employer, or third party administrator fails to respond to the PAR, fails to timely deny the PAR in accordance with subdivision (b) of this section, or, except if the basis for the denial is one of the reasons set forth in clause (b)(2)(i)(b) or (c) or subdivision ( a) of this section, fails to submit the written report, or identify the report in the electronic case folder, the variance may be deemed approved on the ground that such approval was unreasonably withheld and the Chair will issue an order stating that the request is approved and the carrier, self-insured employer or third-party administrator shall be subject to a penalty pursuant to section 25 (3)(e) of the Workers' Compensation Law. Such order of the Chair is not appealable under Workers' Compensation Law section 23. When a substantially similar PAR has been submitted in violation of paragraph (a)(7) of this section, the failure of the carrier, self-insured employer or third party administrator to timely deny such request shall not result in the PAR being deemed approved and the Chair is not required to issue an order stating that the request is approved. 9. When the Chair issues an order as provided in paragraph (8) of this subdivision in a claim that is controverted or the time to controvert the claim has not expired, the insurance carrier, self-insured employer or third party administrator shall not be responsible for the payment of such medical care until the question of compensability is resolved and then only if that insurance carrier,, self-insured employer or third party administrator is found liable for the claim. 1. All requests for review of denials or partial approvals of a PAR by a Carrier's Physician shall be submitted to the Medical Director's Office in the format prescribed by the Chair. 2. When a denial is based on a reason set forth in (b)(2)(i)(b), in addition to a Carrier's Physician review, the request for review shall be submitted to the Medical Director's Office. 3. When a denial or partial approval is based upon an independent medical examination, the medical provider may request review by the Medical Director's Office unless a request for further action through adjudication is filed by the claimant. In the event a decision is rendered by the Medical Director's Office, the claimant retains the rights set forth in subparagraph (7) herein. 4. The Chair or Medical Director may designate private entities to evaluate such requests for review of denials by the carrier's physician provided that the entity has: i. the appropriate URAC accreditation or such accreditation/certification as designated by the Chair, ii. other demonstrated expertise and criteria established by the Board; and iii. no conflict of interest exists in resolving the subject dispute. i. the appropriate URAC accreditation or such accreditation/certification as designated by the Chair, ii. other demonstrated expertise and criteria established by the Board; and iii. no conflict of interest exists in resolving the subject dispute. 5. When a medical provider wishes to request review of a denial or partial approval of a PAR, the medical provider shall submit the request to the Medical Director's Office in the format prescribed by the Chair within 10 calendar days of the denial date together with all documentation submitted in support of its initial request, and the denial or partial approval issued following request. 6. A decision by the Medical Director's Office (or designated accredited entity) is final and binding on the medical provider, and upon the carrier for issues related to medical necessity. Such decision shall be binding and not appealable under Workers' Compensation Law section 23. 7. Notwithstanding paragraph (5) and (6) herein, a claimant may request review of a Medical Director's Office decision or a denial by Carrier's Physician by filing a Request for Further Action that demonstrates that such treatment is medically necessary. A Request for Further Action following denial by a Carrier's Physician shall render a request for review by the Medical Provider to the Medical Director's Office moot. Decision on the denial will be made in Adjudication. The Board may respond to such requests for review by letter or by referral to adjudication, including the expedited hearing process, as appropriate in the discretion of the Chair or his or her designee. 8. If the insurance carrier, self-insured employer, or third party administrator fails to respond to the PAR, fails to timely deny the PAR in accordance with subdivision (b) of this section, or, except if the basis for the denial is one of the reasons set forth in clause (b)(2)(i)(b) or (c) or subdivision ( a) of this section, fails to submit the written report, or identify the report in the electronic case folder, the variance may be deemed approved on the ground that such approval was unreasonably withheld and the Chair will issue an order stating that the request is approved and the carrier, self-insured employer or third-party administrator shall be subject to a penalty pursuant to section 25 (3)(e) of the Workers' Compensation Law. Such order of the Chair is not appealable under Workers' Compensation Law section 23. When a substantially similar PAR has been submitted in violation of paragraph (a)(7) of this section, the failure of the carrier, self-insured employer or third party administrator to timely deny such request shall not result in the PAR being deemed approved and the Chair is not required to issue an order stating that the request is approved. 9. When the Chair issues an order as provided in paragraph (8) of this subdivision in a claim that is controverted or the time to controvert the claim has not expired, the insurance carrier, self-insured employer or third party administrator shall not be responsible for the payment of such medical care until the question of compensability is resolved and then only if that insurance carrier,, self-insured employer or third party administrator is found liable for the claim. --- ## 12 NYCRR § 324.4 — PARs confirming consistency with MTG or medical necessity when no MTG {#324.4} *N.Y. Comp. Codes R. & Regs. tit. 12, § 324.4* Official source: _Aggregated from public-domain New York law; last amended effective 2021-06-07._ (a) Every insurance carrier, self-insured employer and third-party administrator shall designate a qualified employee or employees as a point of contact for the Board and Treating Medical Providers regarding PARs to confirm consistency with the Medical Treatment Guidelines or medical necessity. Insurance carriers, self-insured employers and third-party administrators shall provide the Chair or his or her designee in the manner prescribed by the Chair with the name and contact information for the point(s) of contact for PARs to confirm consistency with the Medical Treatment Guidelines (PAR: MTG Confirmation) or review for medical necessity (PAR: Non-MTG $1,000 or Under). Such contact information may include the contacts' direct telephone number(s) and email address(es). 1. If the designated point(s) of contact changes at any time for any reason, the insurance carrier, self-insured employer or third-party administrator shall notify the Chair or his or her designee of such change in the manner prescribed by the Chair. 2. The list of designated points of contact for each insurance carrier, self-insured employer and third-party administrator shall be maintained by the Board electronically. When a treating medical provider submits a PAR electronically, it shall be directed to the appropriate contact person. Any change in the designated contact shall not be effective until the designated contact information has been updated in the Board's electronic records. 3. In the event that an insurance carrier, self-insured employer or third-party administrator fails to so provide the Chair or his or her designee with such name and contact information (in the manner prescribed), or provides incorrect or incomplete contact information during initial registration or when updating pursuant to subparagraph (1) of this subdivision, such insurance carrier, self-insured employer or third-party administrator may be subject to: i. Orders of the Chair granting any PAR submitted during such time when the name and contact information is missing, incomplete or incorrect; and ii. Penalties issued pursuant to section 114-a (3) of the Workers' Compensation Law for every case, where a PAR was requested. 1. If the designated point(s) of contact changes at any time for any reason, the insurance carrier, self-insured employer or third-party administrator shall notify the Chair or his or her designee of such change in the manner prescribed by the Chair. 2. The list of designated points of contact for each insurance carrier, self-insured employer and third-party administrator shall be maintained by the Board electronically. When a treating medical provider submits a PAR electronically, it shall be directed to the appropriate contact person. Any change in the designated contact shall not be effective until the designated contact information has been updated in the Board's electronic records. 3. In the event that an insurance carrier, self-insured employer or third-party administrator fails to so provide the Chair or his or her designee with such name and contact information (in the manner prescribed), or provides incorrect or incomplete contact information during initial registration or when updating pursuant to subparagraph (1) of this subdivision, such insurance carrier, self-insured employer or third-party administrator may be subject to: i. Orders of the Chair granting any PAR submitted during such time when the name and contact information is missing, incomplete or incorrect; and ii. Penalties issued pursuant to section 114-a (3) of the Workers' Compensation Law for every case, where a PAR was requested. i. Orders of the Chair granting any PAR submitted during such time when the name and contact information is missing, incomplete or incorrect; and ii. Penalties issued pursuant to section 114-a (3) of the Workers' Compensation Law for every case, where a PAR was requested. (b) Submission by Medical provider (1) The Treating Medical Provider has the option of submitting a PAR to the insurance carrier, self-insured employer or third-party administrator to confirm that the proposed medical care is consistent with the Medical Treatment Guidelines. (2) If there is no applicable Medical Treatment Guideline and the cost of the requested treatment is less than $1000 in the aggregate, the Treating Medical Provider has the option of submitting a PAR to the insurance carrier, self-insured employer or third-party administrator for such causally related medically necessary treatment and care. To request to confirm consistency with the Medical Treatment Guidelines (PAR: MTG Confirmation) or medical necessity (PAR: Non-MTG $1,000 or Under), the Treating Medical Provider shall submit the request in the manner prescribed by the Board . The PAR to confirm consistency with the Medical Treatment Guidelines or medical necessity request shall be in the format prescribed by the Chair which may be electronic. (1) The Treating Medical Provider has the option of submitting a PAR to the insurance carrier, self-insured employer or third-party administrator to confirm that the proposed medical care is consistent with the Medical Treatment Guidelines. (2) If there is no applicable Medical Treatment Guideline and the cost of the requested treatment is less than $1000 in the aggregate, the Treating Medical Provider has the option of submitting a PAR to the insurance carrier, self-insured employer or third-party administrator for such causally related medically necessary treatment and care. To request to confirm consistency with the Medical Treatment Guidelines (PAR: MTG Confirmation) or medical necessity (PAR: Non-MTG $1,000 or Under), the Treating Medical Provider shall submit the request in the manner prescribed by the Board . The PAR to confirm consistency with the Medical Treatment Guidelines or medical necessity request shall be in the format prescribed by the Chair which may be electronic. (c) The insurance carrier, self-insured employer or third-party administrator has eight business days from submission of the PAR to confirm consistency with the Medical Treatment Guidelines or medical necessity, and to approve or deny the medical care. The carrier, self-insured employer or third-party administrator shall send the claimant notice of the approval, partial approval or denial of the PAR. Failure to send the claimant such notice may result in penalties under section 25(3)(e), for failure to file a required report with the Board, and section 13-a (6)(a) of the Workers' Compensation Law. In the event the PAR is submitted prior to creation of a workers' compensation case by the Board in accordance with 300.37(a) of this Chapter, the PAR will be promptly reviewed by the Board to identify the proper carrier, self-insured employer or third-party administrator. Upon such identification, the PAR will be directed by the Board to the proper carrier, self-insured employer, or third-party administrator, who shall have 15 calendar days (or 30 calendar days in the event of an IME) to approve, partially approve or deny the request. In the event the PAR is submitted after creation of a workers' compensation case by the Board in accordance with 300.37(a) of this Chapter but prior to filing the mandatory first report of injury pursuant to section 300.22(b) of this Chapter that identifies a third-party administrator responsible for handling the claim, the request may be directed to a third-party administrator that has been designated by the carrier or self-insured employer as handling all or a portion of its workers' compensation claims and identified by the Board as the third-party administrator where such requests will be directed. Such third-party administrator shall have 8 business days to approve, partially approve or deny the request. In the event the PAR is submitted after the mandatory first report of injury pursuant to section 300.22(b) of this Chapter shall become due and no such report has been filed, the Board may issue an Order of the Chair or Notice of Resolution granting the requested treatment. Unless the PAR is made in a case that has been closed, disallowed or cancelled, where ongoing medical treatment is resolved by an agreement pursuant to section 32 of the Workers' Compensation Law, or controverted in accordance with section 300.22(b)(1)(ii) or (c)(1) of this Chapter, any PAR must be reviewed by the insurance carrier, self-insured employer or third-party administrator Carrier's Physician before it may be denied or partially approved. When an insurance carrier, self-insured employer, or third-party administrator denies or partially approves a PAR, the insurance carrier, self-insured employer, or third-party administrator must also assert any other basis for denial or such basis for denial will be deemed waived. Except as set forth in subparagraph (2) below, all denials or partial approvals must be made by the Carrier's Physician. A partial approval limits the length of time or frequency of the treatment, or authorizes a related but different treatment than that requested in the PAR. (1) If the insurance carrier, self-insured employer or third-party administrator agrees that the medical care for which a PAR is requested is consistent with the Medical Treatment Guidelines or is medically necessary, it shall respond in the format prescribed by the Chair. (2) The insurance carrier, self-insured employer or third-party administrator may deny a PAR without review by the Carrier's Physician when a case is closed, disallowed or cancelled, where ongoing medical treatment is resolved by an agreement pursuant to section 32 of the Workers' Compensation Law, or controverted in accordance with section 300.22(b)(1)(ii) or (c)(1) of this Chapter. (i) Nothing herein shall prohibit an insurance carrier, self-insured employer or third-party administrator from obtaining an opinion from an independent medical examiner. (ii) When a PAR is denied without review by Carrier's Physician there shall be no review by the Medical Director's Office. A claimant may request review by the Board by filing a Request for Further Action, that demonstrates that the basis for denial is factually inaccurate. The Board may respond to such requests for review by letter or by referral to adjudication, as appropriate in the discretion of the Chair or his or her designee. (3) A denial of the PAR for reasons other than those set forth in subparagraph (2) of this subdivision, or an approval that concedes medical necessity but does not affirm that the approved medical care will be paid at the fee schedule rate, must be reviewed by the Carrier's Physician. A denial issued by other than a Carrier's Physician is not valid and may be deemed approved by the Board. Invalid denials may be subject to penalties pursuant to sections 13-a (6)(a) and 114-a (3) of the Workers' Compensation Law. (4) If the insurance carrier, self-insured employer or third-party administrator concedes the medical necessity of the medical care, it may grant without liability, only if the case has been controverted in accordance with section 300.22(b)(1)(ii) or (c)(1) of this Chapter, or the medical care is for a body part or condition that has not been accepted by the insurance carrier, self-insured employer or third-party administrator or established by the Board. (5) If the insurance carrier, self-insured employer or third-party administrator fails to respond to a PAR within eight business days, the medical care may be deemed approved on the ground that approval was unreasonably withheld and the Chair will issue an order stating that the request is approved. In addition, the carrier, self-insured employer or third-party administrator shall be subject to a penalty pursuant to section 25 (3)(e) of the Workers' Compensation Law. (1) If the insurance carrier, self-insured employer or third-party administrator agrees that the medical care for which a PAR is requested is consistent with the Medical Treatment Guidelines or is medically necessary, it shall respond in the format prescribed by the Chair. (2) The insurance carrier, self-insured employer or third-party administrator may deny a PAR without review by the Carrier's Physician when a case is closed, disallowed or cancelled, where ongoing medical treatment is resolved by an agreement pursuant to section 32 of the Workers' Compensation Law, or controverted in accordance with section 300.22(b)(1)(ii) or (c)(1) of this Chapter. (i) Nothing herein shall prohibit an insurance carrier, self-insured employer or third-party administrator from obtaining an opinion from an independent medical examiner. (ii) When a PAR is denied without review by Carrier's Physician there shall be no review by the Medical Director's Office. A claimant may request review by the Board by filing a Request for Further Action, that demonstrates that the basis for denial is factually inaccurate. The Board may respond to such requests for review by letter or by referral to adjudication, as appropriate in the discretion of the Chair or his or her designee. (i) Nothing herein shall prohibit an insurance carrier, self-insured employer or third-party administrator from obtaining an opinion from an independent medical examiner. (ii) When a PAR is denied without review by Carrier's Physician there shall be no review by the Medical Director's Office. A claimant may request review by the Board by filing a Request for Further Action, that demonstrates that the basis for denial is factually inaccurate. The Board may respond to such requests for review by letter or by referral to adjudication, as appropriate in the discretion of the Chair or his or her designee. (3) A denial of the PAR for reasons other than those set forth in subparagraph (2) of this subdivision, or an approval that concedes medical necessity but does not affirm that the approved medical care will be paid at the fee schedule rate, must be reviewed by the Carrier's Physician. A denial issued by other than a Carrier's Physician is not valid and may be deemed approved by the Board. Invalid denials may be subject to penalties pursuant to sections 13-a (6)(a) and 114-a (3) of the Workers' Compensation Law. (4) If the insurance carrier, self-insured employer or third-party administrator concedes the medical necessity of the medical care, it may grant without liability, only if the case has been controverted in accordance with section 300.22(b)(1)(ii) or (c)(1) of this Chapter, or the medical care is for a body part or condition that has not been accepted by the insurance carrier, self-insured employer or third-party administrator or established by the Board. (5) If the insurance carrier, self-insured employer or third-party administrator fails to respond to a PAR within eight business days, the medical care may be deemed approved on the ground that approval was unreasonably withheld and the Chair will issue an order stating that the request is approved. In addition, the carrier, self-insured employer or third-party administrator shall be subject to a penalty pursuant to section 25 (3)(e) of the Workers' Compensation Law. (d) If a claim is controverted or the time to controvert the claim has not expired, and the insurance carrier, self-insured employer or third-party administrator agrees that the medical care for which a PAR is requested is consistent with the Medical Treatment Guidelines or is medically necessary, such agreement shall not be construed as an admission that the condition for which the PAR is requested is compensable and the insurance carrier, self-insured employer or third-party administrator is not liable for the cost of such treatment unless the claim or condition is established. (e) For requests made pursuant to (b)(1) herein, if the insurance carrier, self-insured employer or third-party administrator denies that the medical care for which a PAR is requested is consistent with the Medical Treatment Guidelines, the Treating Medical Provider may elect to submit a PAR (PAR: MTG Variance) in accordance with section 324.3 of this Part or submit a request for review . The Treating Medical Provider may request review of the denial of the PAR within 10 calendar days of the date of the denial by submission of the request in the format prescribed by the Chair which may be electronic. The Medical Director's Office shall rule on whether the medical care is consistent with the Medical Treatment Guidelines and issue a notice of resolution setting forth the ruling and the basis for such ruling . Such notice of resolution is binding and not appealable under Workers' Compensation Law Section 23. (f) For requests made pursuant to (b)(2) herein, if the insurance carrier, self-insured employer or third-party administrator denies that the medical care for which prior approval is requested is causally related or medically necessary, the Treating Medical Provider may submit a request for review in the format prescribed by the Chair. Upon the request of the Treating Medical Provider, the PAR and denial will be referred to conciliation for a determination as to whether the medical care is causally related and medically necessary. Conciliation shall issue a proposed conciliation decision setting forth the ruling and the basis for such ruling. The claimant and insurance carrier, self-insured employer or third-party administrator may object to the proposed conciliation decision within thirty calendar days in accordance with part 312 of this Chapter. The Treating Medical Provider may not object to the proposed conciliation decision. (g) An insurance carrier, self-insured employer or third-party administrator may not dispute a bill for medical care on the basis that it was not consistent with the Medical Treatment Guidelines or that it was not causally related or medically necessary, if it has approved a request for prior approval for such medical care or the Board has issued a decision approving the treatment or an Order of the Chair. (h) An insurance carrier, self-insured employer, or third-party administrator may not object to or deny payment of a medical bill solely because the treating medical provider did not submit a PAR under this section prior to rendering treatment. Denial of a medical bill solely for this reason may result in a penalty pursuant to sections 13-a(6) and 114-a(3). --- ## 12 NYCRR § 324.5 — Conditions, treatments, or diagnostic tests not addressed by medical treatment guidelines {#324.5} *N.Y. Comp. Codes R. & Regs. tit. 12, § 324.5* Official source: _Aggregated from public-domain New York law; no amendment recorded since codification._ If the medical treatment guidelines do not address a condition, treatment or diagnostic test for a part of the body covered by the medical treatment guidelines, then the factors in section 324.3(a)(3) of this Part and relevant medical literature as described in section 324.3(a)(4) of this Part shall be used to determine whether the insurance carrier or special fund shall be obligated or not obligated to pay for the medical care at issue. --- ## 12 NYCRR § 324.6 — Incorporation into policies, procedures and practices {#324.6} *N.Y. Comp. Codes R. & Regs. tit. 12, § 324.6* Official source: _Aggregated from public-domain New York law; no amendment recorded since codification._ Insurance carriers and special funds shall incorporate the medical treatment guidelines set forth in section 324.2(a) and (b) and the provisions in sections 324.3(b), 324.4(a), and 324.5 of this Part, and section 325-1.25 of this Title into their policies, procedures, and practices so that their utilization review and management criteria are consistent with the medical treatment guidelines. Insurance carriers and special funds shall have certified to the chair within 120 days of the effective date of this Part that they have done so and shall re-certify to the incorporation of the medical treatment guidelines and the regulatory provisions cited in the previous sentence within 60 days of any changes to their policies, procedures, and practices. The chair and Insurance Department will conduct audits of insurance carriers and special funds with respect to the accuracy of the certifications. Each insurance carrier shall submit the policies and procedures incorporating the medical treatment guidelines incorporated by reference in section 324.2(a) and (b) of this Part and the provisions in sections 324.3(b), 324.4(a), and 324.5 of this Part, and section 325-1.25 of this Title to the chair or Insurance Department in connection with such audit.