Miller Criteria

MCOs formulate policies and procedures that govern provision of medical treatments and services, including either authorization or denial. The available medical evidence must not only support any decision, but also conform to law and legal precedent. One of the most significant legal requirements has been imposed by the case of State, ex rel. Miller v. Indus. Comm., 71 Ohio St. 3d 229 (1994). The Miller case mandates that a three-pronged test be applied when considering requests for authorization of workers’ compensation medical services. Requests are evaluated using a three-pronged test composed of the following:

·         The requested medical services are reasonably related to the industrial injury;

·         The requested services are reasonably necessary and appropriate for the treatment of the industrial injury (allowed conditions);

·         The costs of the services are medically reasonable. 

All three parts of the test must be met to authorize reimbursement of medical services.