ODG Series

Part II: Proper Use of Guidelines

General Rules/Facts Related to the Proper Use versus Misuse of Guidelines

• Please consider the following issues when using guidelines:
  All guidelines serve merely as background information to assist doctors in the clinical decision-
  making process.
• A guideline serves as a compass for care, not a cookbook for care.
• Guidelines should never be used punitively, or as prescriptions for care.
• Each patient is unique and treatment recommendations must be based on the specific factors
  pertaining to the individual case.
• Guidelines are only one piece of evidence to consider when considering the medical necessity of
  care. Other pieces of evidence include research, clinical experience/decision-making, patient
  values, risk stratification, process of care, response to care, documentation, etc. Again, guidelines
  are not cookbooks with rigid dosages for treatment.
• Nearly all guidelines, including the OSCA Guidelines (which is nothing more than a more
  readable distillation of Mercy), ACOEM, ODG, Milliman and Roberston, etc., are based upon the
  acute, non-complicated patient. Chronic care recommendations are limited in most guidelines
  due to the logistical challenges of conducting long-term research, thus the lack of research on
  long-term care for nearly all types of treatment. However, those patients still need care despite
  the limited recommendations in most guidelines, therefore one must also rely on clinical decision-
  making, patient values, the response to care, comorbidities, complicating factors, etc.
• Each case is unique and may present with many complications that should be reported and considered to help clarify why treatment may have extended beyond the natural healing time, or expected recovery time, compared to a non-complicated, mild, acute case. ODG-IMEs/reviewers MUST consider Appendix D to consider complicating factors/co-morbidities that may explain the uniqueness of the case and the reason why care may have extended beyond average treatment recommendations.
• Any reviewer/consultant who recommends a denial based upon his/her belief that a guideline was exceeded should be challenged to produce the page, paragraph, and sentence in the guideline being referenced indicating where the POR/DC exceeded the guideline. If he/she cannot produce the page, paragraph, and sentence, one can only assume he/she either intentionally misinterpreted the document, or even worse, never actually read it and simply fabricated the issue for denial purposes. In our opinion, this behavior is unethical and substantially below the level of professional conduct expected by a licensed consultant/reviewer/attorney.