We have seen public and medical perspectives shift drastically on what constitutes appropriate care. Look no further than the ongoing national evolution surrounding medicinal cannabis, moving from the criminalized Reefer Madness mindset of my youth to a clinically debated alternative. What we know about medicine changes, and our utilization review (UR) systems have evolved to reflect that by demanding objective, scientifically backed data.
Yet, here is the problem I see across claims departments every single day: while the science and the statutes have evolved, our communication strategies are stuck in the past.
Texas Labor Code (§408.021 and §401.011) is clear. We are required to provide care that is “reasonably required,” meaning it must be clinically appropriate, effective, and consistent with evidence-based medicine standards such as those published in the Official Disability Guidelines (ODG). But when a treatment request is non-certified because it lacks objective criteria, how do your adjusters handle the fallout? There are several possible solutions to pursue, including the IRR process, which enables injured employees to secure the most appropriate determination.
Too often, we hide behind the statute. We treat ODG as a rigid shield and tell a frustrated, injured worker, “It was denied because it’s not in the guidelines.”
When an injured employee does not understand a UR denial, they do not think about evidence-based medicine. They think the insurance company is denying their care. Out of frustration, their next phone call is not to the adjuster; it is to complain to anyone who will listen. That is where cost containment completely breaks down. Litigation costs skyrocket, claims stall, and return-to-work percentages plummet.
If we want to protect the claim trajectory, we have to change adjuster behavior. We must bridge the gap between complex clinical guidelines and human frustration. Here is the three-step blueprint your team needs to adopt immediately:
Stop Quoting Statutes; Explain Function
An injured worker does not care about labor code. They care about getting better. When treatment is denied, do not just send a form letter. Explain that evidence-based medicine looks for measurable, functional improvement. Something to the effect of “the reviewing doctor looked at the notes and did not see documentation that your function was improving on this medication. Here is what we need from your treating doctor to address that.” If a claimant has been on opioid analgesics for months, claims their pain is still a 7/10, and has not returned to work, the data shows the medication is not efficacious. Frame the denial around finding a pathway that actually works to restore their function, not just masking symptoms.
Guide the Provider, Do Not Just Blame Them
It is easy to tell a claimant, “Your doctor failed to return the peer-to-peer phone call, so it’s not our fault.” While true, the treating provider has a professional responsibility to document clinical necessity with absolute clarity. Blaming the doctor does not resolve the claimant’s frustration. Teach your adjusters to say: “We want to ensure you get the right care, but we need specific objective data from your doctor’s notes to get this approved. Let’s look at what is missing.”
Remember, Guidelines are Not Concrete Walls
The ODG is a roadmap, not a prison. There is always new clinical data emerging, and the guidelines explicitly leave room for the clinical insight of the reviewing and treating providers. It might very well be that an additional three sessions of physical therapy, even if two exceed the suggested parameters, are clinically indicated to achieve full resolution. Adjusters must look at the entirety of the clinical situation, not just a checkbox.
The Bottom Line
Open, transparent communication between the claim handler and the injured employee can resolve frustrations relatively easily. By teaching your team to explain the why behind evidence-based medicine rather than hiding behind a denial letter, you defuse anger, bypass litigation, and steer the claim toward a faster, more cost-effective closure.
