What Medical Treatment Does Workers’ Compensation Cover in California?

Understanding Workers’ Compensation Medical Benefits in California

When employees suffer a work-related injury, they must receive the right medical treatment for recovery. California’s workers’ compensation system ensures that injured workers receive necessary medical care at no personal cost. However, many workers struggle to understand exactly what treatments are covered, how to request medical care, and what to do if their treatment is denied.

At Mehlhop & Vogt Law Offices, we have spent decades helping injured workers in Sacramento and Northern California secure the medical care and benefits they deserve. Below, we break down what medical treatment workers’ compensation covers, how to get approved care, and what steps to take if your treatment request is denied.

Key Medical Treatments Covered by Workers’ Compensation

Emergency and Urgent Care

A workplace injury can happen at any time, often requiring immediate medical attention. California workers’ compensation provides emergency and urgent care coverage to ensure injured employees receive the treatment they need without delay.

• If your injury poses a life-threatening risk or requires immediate care, visit the nearest hospital emergency room. Workers’ compensation covers emergency room visits, diagnostic tests, and necessary procedures related to your work injury.
• If your condition is urgent but not life-threatening, your employer may direct you to an urgent care center within their Medical Provider Network (MPN).
• Inform your employer as soon as possible after receiving emergency care to ensure proper claim processing.

If you have questions about emergency treatment and claim procedures, visit our Workers’ Compensation page for more information.

Doctor Visits and Specialist Care

Workers’ compensation covers all reasonable and necessary doctor visits for work-related injuries. After reporting your injury, a treating physician will manage your medical care.

• Initial evaluations help determine the extent of your injuries and the treatment needed.
• Ongoing care, including follow-up visits, remains covered to monitor recovery.
• If your condition requires specialized treatment, workers’ compensation may approve visits to orthopedic specialists, neurologists, pain management doctors, or other medical experts.

In California, your employer or insurance company may require you to see a doctor within their Medical Provider Network (MPN). However, in some cases, you may have the right to pre-designate your personal physician. Learn more about how to choose a doctor on our FAQs page.

Hospitalization and Surgery

For serious injuries requiring hospitalization or surgery, workers’ compensation fully covers necessary treatments when medically appropriate.

• If a doctor determines that surgery is necessary, the claims administrator must approve the procedure.
• Hospital stays, pre-surgical evaluations, post-surgical care, and rehabilitation fall under workers’ compensation coverage.
• Common work-related surgeries include spinal procedures, knee or shoulder repairs, carpal tunnel release, and fracture treatments.

If you face delays or denials for a recommended surgery, contact us for assistance. We can help appeal a denial and ensure your workers’ comp medical benefits remain protected.

Physical Therapy and Rehabilitation

Recovering from a workplace injury often requires physical therapy or rehabilitation services to regain mobility and strength. Workers’ compensation covers physical therapy, but your treating physician must prescribe it, and utilization review (UR) approval is required.

• Therapy sessions help workers recover from muscle strains, fractures, back injuries, and post-surgical conditions.
• Occupational therapy may also be available for workers who need to regain skills necessary for job duties.
• Chiropractic treatment remains an option but is subject to limitations under California workers’ comp laws.

Understanding your right to rehabilitation services is crucial. If your physical therapy has been denied or reduced, we can assist in challenging the decision.

Prescription Medications and Medical Equipment

Workers’ compensation covers medications necessary for pain management and recovery when prescribed by an authorized workers’ comp doctor.

• Commonly covered prescriptions include pain relievers, anti-inflammatory medications, and post-surgical medications.
• Some medications require preauthorization, and long-term opioid use is closely monitored under California’s workers’ compensation guidelines.
• Medical equipment such as braces, crutches, wheelchairs, or prosthetics qualifies for coverage when deemed medically necessary.

If you face difficulties filling a workers’ comp prescription or obtaining necessary medical supplies, reach out to us for support.

Chiropractic Care and Alternative Treatments

In specific cases, workers’ compensation covers alternative treatments when they are medically necessary and approved.

• Chiropractic treatment is permitted but is limited to 24 visits, unless further care receives authorization.
• Acupuncture and pain management injections may be approved if conventional treatments fail to relieve symptoms.
• Massage therapy and holistic treatments are generally excluded unless a doctor deems them necessary.

If you believe alternative treatments would benefit your recovery, discuss options with your doctor and legal counsel to pursue approval.

Psychological and Mental Health Treatment

California recognizes that workplace injuries can lead to psychological distress. Workers’ compensation may cover mental health treatment, particularly in cases involving:

• Post-Traumatic Stress Disorder (PTSD) resulting from a traumatic work incident.
• Severe anxiety or depression linked to a work-related injury.
• Mental health conditions caused by workplace violence or harassment.

However, mental health treatment often requires additional medical documentation and approval. If your claim is denied, we can help you file an appeal.

Home Health Care and Attendant Care

For severely injured workers, in-home medical care may be necessary for daily assistance. Workers’ compensation can cover:

• In-home nursing services for wound care, medication administration, or health monitoring.
• Attendant care for workers who cannot perform daily tasks such as bathing, dressing, or mobility assistance.
• Long-term home health care for catastrophic injuries that prevent independent living.

If you or a loved one needs home health care after a work injury, reach out to ensure proper medical care and assistance.

How to Request Medical Treatment Under Workers’ Compensation

Navigating California’s workers’ compensation system can feel overwhelming, especially when it comes to accessing medical treatment. While the law guarantees medical benefits for work-related injuries, following the right steps ensures that you receive timely care. Understanding your rights and using the correct procedures will help you avoid delays or denials.

1. Reporting Your Injury and Seeking Immediate Care

The first step to obtaining workers’ comp medical benefits involves reporting your injury to your employer as soon as possible. California law requires injured workers to notify their employer within 30 days to remain eligible for benefits.

• Step 1: Inform Your Employer – Provide a written or verbal report detailing your injury, how it happened, and when it occurred.
• Step 2: Seek Immediate Medical Care – If your injury requires urgent care, visit an emergency room or urgent care facility. Your employer’s workers’ compensation insurance should cover the treatment.
• Step 3: Complete a DWC-1 Claim Form – Your employer must give you a Workers’ Compensation Claim Form (DWC-1) within one business day. Completing and submitting this form officially starts your claim.

After filing your claim, you have the right to receive medical treatment while your case is under review. California law requires insurance to authorize up to $10,000 in medical treatment while a claim is pending.

If you need help filing a claim or securing medical care, visit our Workers’ Compensation page for more guidance.

2. Choosing a Doctor Under California Workers’ Compensation

Your primary treating physician (PTP) plays a critical role in your recovery. This doctor diagnoses your condition, oversees treatment, and determines work restrictions or disability status. However, your ability to choose a doctor depends on your employer’s insurance policy.

Employer’s Medical Provider Network (MPN)

• Most employers in California use a Medical Provider Network (MPN), a list of approved doctors and specialists for treating injured workers.
• If your employer has an MPN, you must select a doctor from this network unless you predesignated your personal physician before the injury.
• If you are unsatisfied with your initial doctor, you can request a second opinion from another MPN provider.

Predesignating Your Own Doctor

• Some workers prefer to use their personal doctor instead of an MPN provider.
• To predesignate a doctor, you must submit a written request to your employer before an injury occurs, and your physician must agree to treat you under workers’ comp.
• If your employer does not have an MPN, you may have the right to choose your doctor after 30 days of treatment.

If you are unsure whether you can switch doctors or feel that you are not receiving proper care, consult an experienced workers’ comp attorney. Visit our FAQs page for answers to common concerns about medical treatment.

3. Getting Medical Treatment Approved

Not all medical treatments receive automatic approval under California workers’ compensation. Before undergoing certain procedures, taking prescribed medications, or receiving therapy, your doctor must submit a treatment request for approval. This process is known as utilization review (UR).

Understanding Utilization Review (UR)

• Utilization Review (UR) is a system that ensures all medical treatments are medically necessary and appropriate for the injury.
• A claims administrator reviews the treatment request based on California’s Medical Treatment Utilization Schedule (MTUS), which outlines approved treatments for work injuries.
• If a doctor recommends a treatment not listed in the approved guidelines, the request may be delayed or denied.

Steps to Get Treatment Approved

1. Your doctor submits a treatment request to the claims administrator.
2. The insurance company reviews the request to determine if it meets state-approved medical guidelines.
3. Approval or denial is issued within five business days (or up to 14 days for complex cases).
4. If treatment is denied, you have the right to challenge the decision through an Independent Medical Review (IMR).

If your treatment request faces unnecessary delays or has been denied, you should seek legal assistance. Our attorneys can ensure that you receive the treatment you need. Learn more about our legal team on our Our Firm page.

Get Help with Workers’ Comp Medical Treatment

Requesting medical treatment through California workers’ compensation can be frustrating. However, you don’t have to go through it alone. If you are experiencing delays, denials, or difficulty accessing quality care, we are ready to help.

At Mehlhop & Vogt Law Offices, we fight for injured workers across Sacramento and Northern California to ensure they receive proper medical treatment, wage replacement, and all the benefits they deserve.

Need help with a workers’ comp medical claim? Contact us today for a free consultation: Contact Us.

What to Do If Your Medical Treatment Is Denied

Even though California workers’ compensation covers necessary medical treatment for job-related injuries, insurance companies often deny treatment requests due to strict approval guidelines, utilization review (UR) procedures, or disputes over medical necessity. If your treatment has been denied, you still have options to fight for the care you need.

1. Understanding Why Medical Treatment May Be Denied

A denied treatment request doesn’t mean your case is over. In many situations, medical care is denied due to procedural issues or insurance company tactics aimed at minimizing costs. You need to understand why a denial happened before taking the next steps. Common reasons include:

• The insurance company claims the treatment isn’t medically necessary. They may argue that your doctor’s recommendation doesn’t align with California’s Medical Treatment Utilization Schedule (MTUS).
• Utilization Review (UR) rejected the request. The UR process screens medical treatments before approval, and many claims get denied at this stage.
• Your doctor didn’t submit enough medical evidence. If your physician’s documentation lacks detail, the insurer may refuse to authorize care.
• The insurance company disputes whether the injury relates to work. They may argue that your condition resulted from a pre-existing issue rather than a workplace injury.
• Your treatment exceeds state-imposed limits. California places restrictions on certain treatments, such as physical therapy or chiropractic care, unless additional sessions receive approval.

Denials often happen because insurance companies prioritize cost-saving over worker recovery. However, workers’ compensation law gives you the right to appeal.

2. Steps to Appeal a Denied Medical Treatment

If Utilization Review (UR) denies or modifies your treatment request, you can challenge the decision through an Independent Medical Review (IMR). Following these steps will help you fight for the care you need.

Step 1: Carefully Review the Denial Letter

After a denial, the insurance company must send a written notice explaining why they rejected the request. You should examine this letter closely and note:

• The stated reason for the denial.
• Any missing information that might strengthen your case.
• The process for submitting an appeal.

Understanding the denial reason will help you prepare a stronger case.

Step 2: Request an Independent Medical Review (IMR)

California allows injured workers to appeal treatment denials by requesting an Independent Medical Review (IMR) through the California Division of Workers’ Compensation (DWC). A neutral medical expert will review your case to determine if the requested treatment is necessary.

• You must submit an IMR request within 30 days of receiving the denial.
• An independent doctor evaluates your medical records and the recommended treatment.
• If the IMR overturns the denial, the insurance company must approve and authorize your treatment without delay.

IMR appeals often succeed when strong medical evidence supports the claim. If you need help filing an IMR request, we can guide you through the process.

Step 3: Strengthen Your Medical Evidence

A well-documented medical history improves the chances of winning an appeal. If your treatment was denied due to insufficient documentation, consider the following:

• Ask your treating physician to provide additional reports detailing why the treatment is necessary.
• Seek a second opinion from another doctor within your employer’s Medical Provider Network (MPN).
• If your condition has worsened, ensure that your medical records reflect any new symptoms or complications.

Stronger documentation makes it harder for the insurance company to justify a denial.

Step 4: Get Help from a Workers’ Compensation Attorney

If appeals and documentation haven’t resolved the issue, an experienced workers’ compensation attorney can challenge the denial in court. Many injured workers struggle to get the medical treatment they deserve because insurance companies focus on saving money instead of providing care.

Our legal team can:

• Ensure your medical records contain the necessary evidence.
• Challenge unfair denials through IMR or workers’ compensation appeals.
• Negotiate with insurance companies to prevent unnecessary delays.
• Represent you at Workers’ Compensation Appeals Board (WCAB) hearings if needed.

3. How a Workers’ Compensation Attorney Can Help

Insurance companies often delay, deny, or reduce medical care to limit their costs. Many injured workers don’t realize they have the right to challenge these decisions. When you hire an attorney, you increase your chances of receiving the medical care you deserve.

Benefits of Legal Representation

• Your attorney will handle all paperwork and appeals, ensuring nothing is overlooked.
• They will work with medical professionals to strengthen your case.
• If necessary, your lawyer will take your case to court to secure proper medical treatment.
• Most importantly, you pay nothing upfront—our fees only apply if we win your case.

At Mehlhop & Vogt Law Offices, we have helped countless injured workers successfully challenge medical treatment denials. We know the tactics insurance companies use, and we fight aggressively to ensure our clients get the medical care they need.

Don’t Let a Denied Treatment Delay Your Recovery

If your medical treatment for a work injury has been denied, don’t wait—take action now. The longer you wait, the harder it becomes to overturn a denial and access the care you need.

At Mehlhop & Vogt Law Offices, we fight for injured workers in Sacramento and Northern California to ensure they receive proper medical treatment, wage replacement, and all the benefits they deserve.

Need help with a workers’ comp medical claim? Contact us today for a free consultation: Contact Us.