Can You Challenge MDO-Approved Treatment? Yes — But Know Your Grounds

By: Leonardo Lampret, Associate Attorney

When the New York Workers’ Compensation Board’s Medical Director’s Office (MDO) approves a request for medical treatment or medication, the approval is almost always limited to medical necessity. This often leads to confusion among carriers and employers, who may mistakenly believe that an MDO authorization resolves all issues related to the treatment. In reality, MDO decisions do not resolve legal questions, such as causal relationship, liability, or whether the condition or body site has been established.

An MDO’s approval means only that the proposed treatment meets the Medical Treatment Guidelines (MTGs) and is medically necessary for the condition as presented. It does not mean the treatment is causally related to the compensable injury, nor does it signify that the claim itself has been accepted or established. The decision typically contains express language clarifying this limitation.

Once the MDO approves treatment, you cannot file an objection based on medical necessity, as that issue has already been decided. While you may still file a Form C-8.1B to preserve your objections, any medical necessity objection will almost certainly be overruled.

However, the MDO decision does not prevent you from raising other objections in C-8.1B, including:

• The claim is controverted, and liability has not yet been resolved.
• The treatment is not causally related to the accepted or established injury or body part.
• The treatment was performed outside a Preferred Provider Organization (PPO), if applicable.
• The medical provider’s report was untimely or legally defective.
• The condition or body part treated is not yet established under the claim.

These objections are legally recognized under 12 NYCRR § 325-1.25(c) and remain available to carriers and employers even after MDO approval.

Recommendations for Carriers and Employers

1. Review the MDO Approval Carefully: Check whether the approval includes standard language limiting the scope to medical necessity.
2. Preserve Legal Defenses Early: If you intend to controvert the claim or dispute causal relationship of the treatment, raise all applicable defenses in C-8.1B.
3. Monitor for Establishment Issues: If the treatment relates to a body part or condition not yet established, be sure to object to preserve your defense.
4. Coordinate With Legal Counsel: In complex cases, consult with your attorney to ensure your objections are properly framed and supported.

In short, while you cannot dispute MDO-authorized treatment on medical necessity grounds, you absolutely can and should raise appropriate legal objections when warranted.