Often a QME or AME will provide recommendations in their report after an evaluation. These recommendations may include diagnostic studies, suggestions that applicant should be referred to a specialist, or future medical recommendations such as physical therapy or medications. What may be confusing is what is required to be authorized as a part of the AME/QME evaluation, and what is subject to a primary treating physician RFA (request for authorization) which would be subject to UR (utilization review) and IMR (independent medical review.)

Generally, a QME or AME treatment recommendation is not a physician recommendation that is subject to UR, as they are not the primary treating physician (PTP). The QME/AME role is to provide neutral opinions, and per CCR 41(s)(4) a QME may even be sanctioned for providing or soliciting to provide treatment to an injured worker.

However, if a QME or AME orders or recommends a diagnostic test as part of the medical legal evaluation, the testing would not be subject to UR, and would be considered a medical legal expense in accordance with Labor Code Section 4620(a), which could include expenses for a diagnostic test, laboratory fee, or x-ray. The request for the diagnostic from a QME must still be necessary, meaning the injured workers’ subjective complaints and physical findings at examination warrant the need for the testing. If the diagnostic recommendation is contingent upon something that has not occurred (“if a surgery ‘x’ happens”, “if applicant’s pain worsens”, “if physical therapy is unsuccessful”, etc.) then that contingent diagnostic request could be argued as not necessary and would need to go through the regular process of being requested by the applicant’s PTP, and be subject to UR and IMR. 

While a QME/AME opinion on future medical care recommendations can at times be helpful for purposes of determining future medical care potential costs, these recommendations are not binding as the QME/AME is not the PTP. Treatment recommendations generally would still need to come from the PTP via a RFA, that would be subject to UR and IMR.

In summary, if the request by a QME or AME for a diagnostic test is necessary for the medical legal evaluation the diagnostic testing would be considered a medical legal expense, and is not subject to UR.