Vermont § 640b - Request for preauthorization to determine if proposed benefits or services are necessary

§ 640b. Request for preauthorization to determine if proposed benefits or services are necessary

• (a) As used in this section: (1) “Benefits” means medical treatment and surgical, medical, and nursing services and
  supplies, including prescription drugs and durable medical equipment. (2) “Services” means medical case management services. (b) Within 14 days after receiving a written request for preauthorization for proposed
  benefits and medical evidence supporting the requested benefits, a workers’ compensation
  insurer shall do one of the following, in writing: (1) Authorize the benefits and notify the health care provider, the injured worker, and
  the Department. (2) Deny the benefits because the entire claim is disputed and the Commissioner has not
  issued an interim order to pay benefits. The insurer shall notify the health care
  provider, the injured worker, and the Department of the decision to deny benefits. (3) Deny the benefits if, based on a preponderance of credible medical evidence specifically
  addressing the proposed benefits, the benefits are unreasonable, unnecessary, or unrelated
  to the work injury. The insurer shall notify the health care provider, the injured
  worker, and the Department of the decision to deny benefits. (4) Notify the health care provider, the injured worker, and the Department that the insurer
  has scheduled an examination of the employee pursuant to section 655 of this title or ordered a medical record review pursuant to section 655a of this title. Based on the examination or review, the insurer shall authorize or deny the benefits
  and notify the Department and the injured worker of the decision within 45 days after
  a request for preauthorization. The Commissioner may, in the Commissioner’s sole discretion,
  grant a 10-day extension to the insurer to authorize or deny benefits, and such an
  extension shall not be subject to appeal. (c) If the insurer fails to authorize or deny the benefits pursuant to subsection (b)
  of this section within 14 days after receiving a request, the claimant or health care
  provider may request that the Department issue an order authorizing benefits. After
  receipt of the request, the Department shall issue an interim order within five days
  after notice to the insurer, and five days in which to respond, absent evidence that
  the entire claim is disputed. Upon request of a party, the Commissioner shall notify
  the parties that the benefits have been authorized by operation of law. (d) If the insurer denies the preauthorization of the benefits pursuant to subdivision
  (b)(2), (3), or (4) of this section, the Commissioner may, on the Commissioner’s own
  initiative or upon a request by the claimant, issue an order authorizing the benefits
  if the Commissioner finds that the evidence shows that the benefits are reasonable,
  necessary, and related to the work injury. (e) Within 14 days after receiving a request for preauthorization of proposed medical
  case management services, the insurer shall do one of the following, in writing: (1) Authorize the services and notify the injured employee, the Department, and the treating
  provider recommending the services, if applicable. (2) Deny the services because the entire claim is disputed, and the Commissioner has not
  issued an interim order to pay benefits. The insurer shall notify the injured employee,
  the Department, and the treating provider recommending the services, if applicable,
  of the decision to deny benefits. (3) Deny the request if there is not reasonable support for the requested services. The
  insurer shall notify the injured employee, the Department, and the treating provider
  recommending the services, if applicable, of the decision to deny benefits. (4) Notify the injured employee, the Department, and the treating provider recommending
  the services, if applicable, that the insurer has scheduled an examination of the
  injured employee pursuant to section 655 of this title or ordered a medical record review pursuant to section 655a of this title. Based on the examination or review, the insurer shall notify the injured employee
  and the Department of the decision within 45 days after a request for preauthorization.
  The Commissioner may, in the Commissioner’s sole discretion, grant a 10-day extension
  to the insurer to authorize or deny the services, and such an extension shall not
  be subject to appeal. (f) If the insurer fails to authorize or deny the services pursuant to subsection (e)
  of this section within 14 days after receiving a request, the injured employee or
  the injured employee’s treating provider, if applicable, may request that the Department
  issue an order authorizing services. After receipt of the request, the Department
  shall issue an interim order within five days after notice to the insurer, and five
  days in which to respond, absent evidence that the entire claim is disputed. Upon
  request of a party, the Commissioner shall notify the parties that the services have
  been authorized by operation of law. (g) If the insurer denies the preauthorization of the services pursuant to subdivision
  (e)(2), (3), or (4) of this section, the Commissioner may, on the Commissioner’s own
  initiative or upon a request by the injured worker, issue an order authorizing the
  services if the Commissioner finds that the evidence shows that the services are reasonably
  supported. (Added 2011, No. 50, § 3; amended 2023, No. 76, § 29, eff. July 1, 2023; 2025, No. 40, § 24, eff. July 1, 2025.)