What Medical Care Can Workers’ Compensation Cover?
Medical treatment in a workers’ compensation claim is different from a medical-malpractice case. For an injured worker, the practical questions are who may provide treatment, whether recommended care is authorized, what happens after a denial, and how medical documentation affects wage and disability benefits.
- Primary treating physician visits and specialist referrals.
- Diagnostic testing when medically supported.
- Physical or occupational therapy and rehabilitation services when appropriate.
- Prescription medication and other medically necessary treatment.
- Durable medical equipment, prosthetics or orthotics when supported by the work injury.
- Reasonable medical and medical-legal travel expenses, including mileage, parking and bridge tolls.
As of July 1, 2026, the DWC medical and medical-legal mileage rate is 76 cents per mile. Keep a contemporaneous mileage log rather than trying to recreate trips months later.
Who Chooses the Treating Doctor?
Doctor-choice questions to answer early
- Does the employer or insurer use an MPN or HCO?
- Did you predesignate an eligible personal physician in writing before the injury?
- If there is no MPN or HCO, who selected the doctor during the first 30 days?
- Have you received the written network information and doctor-change instructions?
How Does Treatment Authorization Work?
- Your primary treating physician identifies the treatment being requested and documents why it is medically necessary.
- The request is transmitted to the claims administrator on the appropriate RFA process.
- When utilization review applies, the administrator reviews the request under the MTUS and issues an approval, modification, delay or denial.
- If medical necessity is denied, delayed or modified through UR, the injured worker may use Independent Medical Review (IMR) to challenge that medical-necessity determination.
Important distinction: a QME can resolve many medical-legal disputes, but a QME is not the normal appeal path for a UR medical-necessity denial. UR/IMR and QME proceedings serve different purposes.
What If Treatment Is Denied or Delayed?
Build a treatment-dispute file
- The treating physician’s RFA and supporting report.
- The UR decision letter and all enclosures.
- Diagnostic reports and specialist recommendations.
- Prior treatment history showing what has or has not worked.
- Pharmacy or therapy denials, if relevant.
- A timeline of missed appointments, delayed authorizations and symptoms affected by the delay.
Can I Receive Medical Care While the Claim Is Still Being Investigated?
The claims administrator should also send a claim-status notice. If no acceptance or denial is issued within 90 days after the completed claim form is provided, California DWC states that the injury is generally presumed covered, subject to the governing law and facts.
When Should I Consider Legal Help With Medical Treatment?
- UR repeatedly denies or modifies treatment your doctor says is necessary.
- You cannot obtain an appropriate specialist within the applicable medical network.
- The insurer is treating a medical-legal dispute as though it were a treatment-authorization dispute, or vice versa.
- Your work status is unclear because medical reports do not state usable restrictions.
- You are being billed directly for care that providers know is or may be work related.
- Treatment delays are affecting temporary-disability payments, permanent-disability evaluation or your ability to return to work.
Frequently asked questions
Can the insurance company decide what treatment I receive?
The treating doctor recommends care, but California uses MTUS medical guidelines and the utilization-review process to determine whether requested treatment is medically necessary. A UR denial or modification can generally be challenged through IMR.
Can I change workers’ comp doctors?
Often yes, but the rules depend on the employer’s MPN/HCO status and whether you predesignated a doctor. Inside an MPN, workers may generally change to another available MPN physician after the first examination.
Do I pay copays for approved workers’ comp treatment?
Workers’ compensation medical treatment for the accepted industrial injury is paid through the workers’ compensation system rather than ordinary patient cost sharing. If a provider is billing you personally, address the issue promptly with the provider and claims administrator.
What is the current medical mileage rate?
For reasonable medical and medical-legal travel on or after July 1, 2026, DWC lists the reimbursement rate as 76 cents per mile. Different rates apply to earlier travel dates.
Is a QME the same as a treating doctor?
No. A QME performs an independent medical-legal evaluation and writes a report used to resolve disputed workers’ compensation issues. The primary treating physician manages ongoing care.