IMPORTANT: PLEASE READ CAREFULLY THE FOLLOWING INFORMATION FOR DETERMINING HOW TO FIND INSURER/SELF-INSURER CONTACTS MG-2, ATTENDING DOCTOR'S REQUEST FOR APPROVAL OF VARIANCE AND INSURER'S RESPONSE This form requires the name and fax number or email address of the insurer's designated contact listed on the Workers' Compensation Board's website. Insurer/Self-Insurer's designated contact information is available online at: wcb.ny.gov/medical-treatment-guideline-variance-requestMG-2.0 (4-18) COVER SHEET Patient's Name:I certify that I am making the above request for approval of a variance and my affirmative statements are true and correct. I certify that I have read and applied the Medical Treatment Guidelines to the treatment and care in this case and that I am requesting this variance before rendering any medical care that varies from the Guidelines. I certify that the patient understands and agrees to undergo the proposed medical care. I contact the insurer by telephone to discuss this variance request before making the request. I contacted the insurer by telephone on and spoke to (person spoke to or was not able to speak to anyone) did / (date) did not The undersigned requests approval to VARY from the WCB Medical Treatment Guidelines as indicated below: ATTENDING DOCTOR'S REQUEST FOR APPROVAL OF VARIANCE AND INSURER'S RESPONSE For additional variance requests in this case, attach Form MG-2.1. Answer all questions where information is known. MG-2MG-2.0 (4-18) Page 1 of 2 WCB Case #: Claim Administrator Claim (carrier case) #: Date of Injury/Illness:FirstMILast Date of service of supporting medical in WCB case file, if not attached:Date(s) of previously denied variance request for substantially similar treatment, if applicable: Employer's Name & Address: Insurer's Name & Address: Social Security No.: Attending Doctor's Name & Address: Approval Requested for: (one request type per form) Patient's Address:STATEMENT OF MEDICAL NECESSITY - See item 5 on instruction page. Your explanation must provide the following information: -the basis for your opinion that the medical care you propose is appropriate for the patient and is medically necessary at this time; and-an explanation why alternatives set forth in the Medical Treatment Guidelines are not appropriate or sufficient. Additionally, variance requests to extend treatment beyond recommended maximum duration/frequency must include: -a description of the functional outcomes that, as of the date of the variance request, have continued to demonstrate objective improvement from thattreatment and are reasonably expected to further improve with additional treatment; and-the specific duration or frequency of treatment for which a variance is requested. Variance requests for treatment or testing that is not recommended or not addressed, must include: -the signs and symptoms that have failed to improve with previous treatments provided according to the Medical Treatment Guidelines; and-medical evidence in support of efficacy of the proposed treatment or testing- may include relevant medical literature published in recognized peerreviewed journals.I sent or directed my office to send a copy of this request to the insurer, the Chair, the patient and the patient's legal representative, if any, on the same day, and sent or directed my office to send a copy to the Workers' Compensation Board within two (2) business days of the date below. In addition, I certify that I do not have a substantially similar request pending and that this request contains additional supporting medical evidence if it is substantially similar to a prior denied request. Provider's Signature: Date: Designated contact information not available.(In first box, indicate injury and/or condition: K = Knee, S = Shoulder, B = Mid and Low Back, N = Neck, C = Carpal Tunnel, P = Non-Acute Pain. In remaining boxes, indicate corresponding section of WCB Medical Treatment Guidelines. If the treatment requested is not addressed by the Guidelines, in the remaining boxes use NONE) - Guideline Reference: Telephone No.: Fax No.: NPI No.: - Individual Provider's WCB Authorization No.: A.Insurer's designated fax # or email address as provided on the Board's website: B.If the request was also submitted to another fax # or email address provided by the insurer, provide here: C.I am not equipped to send or receive forms by fax or email. This form was mailed (return receipt requested) on:Provider must enter in A the designated fax or email address this request was sent to. Insurer/self-insurer's designated contact information is available online at: wcb.ny.gov/medical-treatment-guideline-variance-request. Check "Designated contact information not available", if appropriate. If the request was sent to a different (contact information is not available on Board's website) or additional fax or email address provided by the insurer, complete B. If you are unable to send or receive email or fax, complete C. I request that the Workers' Compensation Board review the insurer's denial of my doctor's request for approval to vary from the Medical Treatment Guidelines. I opt for the decision to be made by the Medical Arbitrator designated by the Chair or through WCB adjudication. I understand that if either party, the insurer or the claimant, opts in writing for resolution through adjudication, the case shall proceed for proposed decision and, if not therein resolved, to a WCB hearing. I understand that if neither party opts for resolution by adjudication, the variance issue will be decided by a medical arbitrator and the resolution is binding and not appealable under WCL 247 23.(Please complete if request is denied.) If the issue cannot be resolved informally, I opt for the decision to be made by the Medical Arbitrator designated by the Chair or through WCB adjudication. I understand that if either party, the insurer or the patient, opts in writing for resolution through adjudication, the case shall proceed for proposed decision and, if not therein resolved, to a WCB Hearing. I understand that if neither party opts for resolution by adjudication, the variance issue will be decided by a medical arbitrator and the resolution is binding and not appealable under WCL 247 23.Insurer's response to the variance request is indicated in the checkboxes on the right. Insurer denial, when appropriate, should be reviewed by a health professional. (Attach written report of medical professional.) If request is approved or denied, sign and date the form in Section E.I certify that copies of this form were sent to the Treating Medical Provider requesting the variance, the Workers' Compensation Board, the claimant's legal representative, if any, and any other parties of interest, with the written report of the medical professional in the office of the insurer/employer/self-insured employer/Special Fund attached, within two (2) business days of the date below.I certify that the provider's variance request initially denied above is now granted or partially granted.MG-2.0 (4-18) Page 2 of 2DENIAL INFORMALLY DISCUSSED AND RESOLVED BETWEEN PROVIDER AND INSURER / EMPLOYERINSURER'S / EMPLOYER'S RESPONSE TO VARIANCE REQUESTCLAIMANT'S / CLAIMANT REPRESENTATIVE'S REQUEST FOR REVIEW OF INSURER'S / EMPLOYER'S DENIAL INSURER'S / EMPLOYER'S NOTICE OF INDEPENDENT MEDICAL EXAMINATION (IME) OR MEDICAL RECORDS REVIEW ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD PRESENTS, CAUSES TO BE PRESENTED, OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, OR SELF-INSURER, ANY INFORMATION CONTAINING ANY FALSE MATERIAL STATEMENT OR CONCEALS ANY MATERIAL FACT SHALL BE GUILTY OF A CRIME AND SUBJECT TO SUBSTANTIAL FINES AND IMPRISONMENT. The self-insurer/insurer hereby gives notice that it will have the patient examined by an Independent Medical Examiner or the claimant's medical records reviewed by a Records Reviewer and submit Form IME-4 within 30 calendar days of the variance request. INSURER'S / EMPLOYER'S RESPONSE If service is denied or granted in part, explain in space provided. Granted Denied Burden of Proof Not Met Substantially Similar Request Pending or Denied Granted