The most common misunderstanding in a New York workers’ compensation claim is this one: people believe the insurance carrier decides what medical treatment they are allowed to have. For most treatment, it does not.
New York has Medical Treatment Guidelines, and they are the standard of care for work injuries in this state. They are mandatory for every payer. If your doctor is treating you in a way that is consistent with the Guidelines, that treatment is already authorized. The carrier does not get to approve it, delay it, or second-guess it. Your provider does not have to ask.
That single fact resolves a great many arguments before they start. When a carrier tells an injured worker that treatment “has not been approved,” the first question is whether approval was ever required.
When approval genuinely is required
There are three situations where your provider does have to ask first.
Certain procedures always require prior authorization, no matter how clearly indicated they are. Lumbar fusion, spinal cord stimulators, knee replacement and repeat surgeries are on that list. These are not exceptions carved out because the treatment is doubtful; they are there because they are major and expensive.
Treatment that departs from the Guidelines requires a variance. The Guidelines are not a complete description of medicine, and sometimes the right care for a particular person is not what the Guidelines contemplate — more physical therapy than the recommended course, a treatment the Guidelines do not address, care continued past the point they anticipate. To get it covered, your provider asks the Board for a variance, and has to show why the Guideline option is not sufficient for you.
Medication is its own process, governed by the drug formulary, with its own timetable described below.
The forms changed, and most advice online is out of date
If you search this subject you will find pages telling you to file an MG-2 for a variance, or a C-4AUTH to get a procedure authorized. Those forms no longer exist.
In 2022 the Board moved the entire process into its OnBoard system, and the MG-1, MG-2, C-4AUTH and HP-1 forms all became obsolete. Everything is now a Prior Authorization Request — a PAR — submitted electronically. There are PARs for medication, for durable medical equipment, for confirming that treatment fits the Guidelines, for variances, and for non-Guideline treatment over $1,000.
This matters practically. Advice built around the old forms is describing a process that no longer runs, and a provider still working from it is going to have problems.
The clocks, and why they matter
A carrier does not get to sit on a request indefinitely. Each kind of request has a deadline.
| Request | Carrier must respond within |
|---|---|
| Medication PAR (each review level) | 4 calendar days |
| Variance from the Medical Treatment Guidelines | 30 calendar days |
| Variance where the carrier wants its own examination first | Notice to your provider within 5 business days, full response within 30 days |
| Appealing a denied medication PAR to the next level | 10 calendar days, on your provider’s side |
Those are calendar days, which include weekends and holidays.
What happens when a carrier misses the medication deadline
This is the part almost nobody knows, and it is worth knowing.
On a medication request, if the carrier does not respond within the four days, an Order of the Chair issues automatically and the request is granted. Not reconsidered. Granted. The status in the system changes to reflect it and your provider is notified.
So a carrier that ignores a medication request does not thereby deny it. It loses. If you have been told a prescription is “still pending” well beyond four days, that is worth looking into rather than waiting on.
If it is denied
A denial is not the end of it, and the route depends on what was denied.
Medication denials move up through three levels of review, described below.
A denied variance can go to the Medical Director’s Office where the denial rested on the carrier’s independent medical examination. Otherwise it goes in front of a Workers’ Compensation Law Judge, which means putting the issue formally before the Board and having it heard.
There is no fast-track arbitrator for a denied variance. It is an ordinary contested issue, decided the way contested issues are decided — on the medical record, at a hearing.
The three levels of review
A denial is not one decision. It is a decision at a level, and which level you are at determines who is looking at it and what can be done about it.
Level 1 is the claim administrator’s own reviewer. This is the first look, and it is worth understanding that at this level the carrier can issue an administrative denial with no physician involved at all — a denial that says, in effect, we are not reaching the medicine. The body part is not established. The claim is controverted. There is no jurisdiction. Nobody has evaluated whether you need the treatment.
Level 2 is the insurer’s physician. If the denial is for medical reasons, or on the ground that your provider did not meet the burden of proof, a doctor has to be involved and has to state the medical rationale — and has to do it within the original response window, not a fresh one. A carrier cannot deny on medical grounds and produce the reasoning later at its convenience.
Level 3 is the Medical Director’s Office at the Board. These are Board physicians, not the carrier’s. This is the first point in the chain at which the person reviewing your treatment is not being paid by the party refusing it, which is the reason getting to Level 3 matters.
Only your doctor can escalate — your lawyer cannot
This surprises people, and it is the single most important practical fact on this page.
Prior authorization runs through OnBoard, the Board’s medical portal. Attorneys are not users of OnBoard. The Board states it plainly: your lawyer does not log in, does not see the request as your doctor sees it, and cannot request Level 2 or Level 3 review. Those escalations can be filed only by the treating provider who asked for the treatment in the first place.
So if the denial arrives and your doctor’s office does not escalate it inside the window — ten calendar days on a medication denial — the treatment is refused and the medical appeal is over. Not because your lawyer let it go. Because it was never your lawyer’s to file.
What an attorney does have is a view of it and a different door. The documents generated by the request land in the case folder in eCase, where your attorney can read them. A claimant’s attorney with an R-number and an email address on file also receives automatic notifications from OnBoard as the request moves — when it is submitted, when the insurer responds, when it is escalated, when the Chair issues an order. That is what makes the difference in an office that is paying attention: the denial is seen the week it happens, and somebody calls the doctor’s office about escalating instead of waiting for you to notice that nothing was ever scheduled.
Then, once the medical track is exhausted or was never the real issue, the attorney files a request for further action and puts it in front of a judge. Which of those is available to you, and when, is the next section.
The one thing worth doing yourself: call your doctor’s office and ask whether they escalated the denial. Do not assume it is being handled.
The answer is not always yes or no
A carrier has three responses available: grant it, grant it in part, or deny it. The middle one, and a modifier that can be attached to either grant, cause most of the confusion in practice.
Granted in part
Your doctor asks for twelve sessions of physical therapy and the carrier approves six. Or the injection is approved and the surgery is not. On paper this reads as an approval, and people treat it as good news.
It is a partial denial, and it carries the same rights as a denial. The portion that was refused can be escalated through the same levels, on the same clocks. What tends to happen instead is that everyone takes the six sessions, works through them, and only discovers the problem when the therapy runs out and the request to continue meets the same resistance — by which time the deadlines on the original refusal are long gone.
Granted without prejudice
This is the one that causes real trouble, and it is the least understood response in the system.
“Without prejudice” is not a separate answer. It is something the carrier can attach to a grant or a partial grant, and it is available in two situations: where your claim is controverted and the dispute is still pending, or where the body part or condition has not been accepted by the carrier or established by a decision of the Board.
What it means is that the carrier is authorizing the treatment without conceding that it is liable for that body part at all. The authorization is real. The payment is conditional.
And that is where it stops being a paperwork distinction. A surgeon looking at an authorization granted without prejudice is looking at an operation that may end in a fight over whether anybody owes them for it. Providers know what that means, and many of them will simply decline to schedule the procedure. The practical result is that you can be holding an approval and still not be able to get the treatment.
People in that position often assume the problem is medical — that the doctor has changed their mind, or is being difficult. It usually is not. The obstacle is that the body part has never been established, and until it is, the authorization is worth less than it appears.
That is a legal problem with a legal fix. Getting the site of injury established, or the controversy resolved, is not something your doctor can do and not something arguing with the carrier will achieve. It is done in front of a judge, and it is often the step that has to happen before the treatment can.
When an attorney can step in, and when they cannot
The attorney’s instrument here is a request for further action — form RFA-1LC — which asks the Board to put the dispute in front of a judge. It is not a substitute for the medical appeal your doctor files, and it is not available in every situation. Whether it is available depends on why the treatment was denied.
| How it was denied | Can your attorney file to bring it before the Board? |
|---|---|
| Administrative denial, or denied for lack of jurisdiction | Yes. This is a legal question, not a medical one, and it belongs in front of a judge. |
| Variance or special services denied on medical grounds, supported by the carrier’s independent medical examination | Yes. There is an examination to challenge, and that is litigable. |
| After a Level 3 response from the Medical Director’s Office | Yes. The medical review has run its course. |
| Non-guideline treatment over $1,000, denied for medical reasons | No filing needed. The Board schedules a hearing automatically. |
| A straightforward medical-necessity dispute still inside the review levels | Not yet. It goes up the medical ladder first. |
The distinction that runs through all of it is medical versus administrative. A fight about whether you need the surgery is a medical question and the Board routes it through physicians. A refusal that never reaches the medicine — the site is not established, the claim is controverted, there is no jurisdiction — is a legal question, and a legal question goes to a judge.
Which is why the reason stated on a denial matters as much as the denial. Carriers sometimes reach for an administrative ground because it is easier than defending the medicine. That can be a mistake on their part: in a controverted case, an administrative denial issued without obtaining an independent medical examination can waive the carrier’s right to get one later on that request. A denial written carelessly can cost the carrier the examination it would have relied on.
None of that is visible to someone reading a denial letter on their own. It is the difference between “they said no” and knowing which of five doors is open.
Why this is hard to do on your own
Here is a detail that says most of what needs saying. The form used to bring a denied treatment issue before the Board is the Request for Further Action by Legal Counsel, and since December 2024 it has to be filed electronically. The name is not an accident.
The deeper problem is that a treatment denial is not really a medical argument by the time it reaches a hearing. It is a record. Whether you get the surgery turns on what is in the file: whether your provider documented the functional gains from what you have already tried, whether the request explained why the Guideline option is not enough for you specifically, whether the carrier’s examiner was cross-examined or left standing unchallenged.
Doctors are treating patients, not building evidentiary records, and most have no particular reason to know what a judge will want to see. That gap is where treatment gets lost.
What to do when treatment is refused
- Ask what was actually denied, and whether authorization was ever required. Treatment within the Guidelines does not need the carrier’s permission.
- Find out the date the request was submitted, so you know which clock is running.
- If it is medication and you are past four days with no answer, say so.
- Get the denial in writing, with the reason given.
- Ask your provider whether they intend to escalate, and by when — ten days goes quickly.
- Do not pay out of pocket for treatment that should be covered before someone has looked at whether the denial was proper.
Talk to us
If a carrier has refused treatment your doctor says you need, call the office at (718) 701-2776. We will tell you whether the denial was procedurally proper, what the deadline is, and what the record needs before a judge sees it.
The consultation is free, and if we don’t recover money for you, we don’t get paid. You will speak with me about your case — see who will handle your case.
Related: independent medical examinations, denied claims and appeals, Section 32 settlements, and our workers’ compensation questions and answers.
This page is general information about New York law and is not legal advice about your own claim. Procedures and timeframes are those in effect as of September 2026.