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.,
· 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.