For injuries occurring on or after January 1, 2004, Labor Code Section 4604.5(c)(1) limits an applicant to twenty-four (24) chiropractic, physical therapy, and occupational therapy treatments. There are; however, three exceptions that allow for additional visits, defined as follows:
a. When the injury occurs prior to 1/1/2004,
b. When an exception is authorized in writing by the claims administrator
c. When services are required in compliance with the post-surgical treatment utilization schedule.
For readers unfamiliar with the post-surgical treatment utilization schedule, it can be found under 8 CCR 9792.24.3. This regulation outlines various types of surgical procedures, the number of additional treatments afforded for those procedures within a certain identified timeline stemming from both the date treatment was resumed and from date of surgery. Unfortunately, many claims adjusters are unfamiliar with the surgical treatment utilization schedule as they mistakenly presume that an injured worker who undergoes surgery is automatically entitled to another 24 visits with a chiropractor, physical therapist or occupational therapist. This is woefully incorrect. An automatic 24 additional visits are not allowed.
Allow us to demonstrate: For a post-surgical meniscectomy, the schedule calls for “12 visits over 12 weeks within six months from the date of surgery.” In addition, the post-surgical services must also be approved by utilization review.
Sometimes chiropractors are selected as an injured worker’s primary treating physician (PTP). Questions may arise concerning what happens once the chiropractor exhausts the 24-treatment limit. Can the chiropractor continue as the PTP to conduct examinations without rendering further chiropractic treatment? Prior to 2013, chiropractors were allowed to remain on as the PTP under these circumstances. However, SB 863, effective January 1, 2013, specifically addressed this issue by declaring that once the 24-visit cap was exhausted a chiropractor could not remain on as the PTP and a new PTP was required. This prohibition was later codified and can be found under LC 4600(c).
So, when in doubt, remember that it’s 24 and out!