The Utilization Review (UR) department determines the medical necessity of services based on an injured employee’s clinical condition. WSI uses evidence-based guidelines from national and state authorities to support these decisions.
Final liability and payment decisions are made by the WSI claims adjuster managing the claim.
Request Types
To submit a prior authorization review request,
- Access the Lookup Claim application to obtain the claim number or status.
- Review this guide to determine if prior authorization is required.
- Submit the prior authorization request in myWSI or complete the appropriate paper form and include supporting documentation.
- To appeal a UR decision, complete the applicable form or submit the request online in myWSI. Submit the appeal with new, relevant medical information that disputes the rationale provided in the UR notification letter.
Upon receipt of all required information, WSI will complete the review within 3 business days.
If a provider does not perform the authorized service within 3 months from the date of approval (6 months for elective spinal fusions), resubmit the request with updated medical information for an additional review.
WSI allows a retrospective review request if the provider has received a denied charge and can demonstrate one of the following conditions:
- The provider was not aware the condition was a work-related injury, or
- The injured employee’s claim status at the time of the service was denied, presumed closed, or not filed.
If neither of the above conditions are present and a retrospective review request is based on the rationale of medical necessity alone, WSI will uphold the denial.
To submit a retrospective review request, submit the request in myWSI or complete the Medical Bill Appeal (M6) form with new, relevant medical information that disputes the rationale provided in the UR notification letter and supports either or both conditions listed above.
Services Requiring Prior Authorization by UR Department
Applicable services: Inpatient Rehab, Inpatient Surgeries, Inpatient Psychiatric, Long Term Acute Care, Subacute, Swing Bed, TCU
Prior authorization instructions: Submit the prior authorization request in myWSI or complete the Prior Authorization Review Request (URC) form at least 24 hours prior to the proposed admission or surgery.
Emergent: No prior authorization is required.
Prior authorization instructions: Submit the Non-Emergent Air Ambulance Facility-to-Facility Request (M13) form by the end of the next business day.
Emergent: No prior authorization is required
Applicable services: Includes Pulsed Electromagnetic Field Therapy
Prior authorization instructions: Submit the prior authorization request in myWSI or complete the Prior Authorization Review Request (URC) form.
Applicable Services: Acute, Subacute
Prior Authorization instructions: Submit the prior authorization request in myWSI or complete the UR Chiropractic Review Request (UR Chiro) form after an initial window period of 10 visits or 60 days of care, whichever occurs first.
- An initial evaluation or re-evaluation visit is included in window periods.
- One initial window period is allowed per claim – not per body part or diagnosis.
- A limit of 2 modalities per visit is allowed during a window period.
An evaluation/re-evaluation may be performed without prior authorization if there has been a lapse (greater than 2 weeks) in chiropractic care. To request continued services, submit the prior authorization request in myWSI or complete the UR Chiropractic Review Request (UR-Chiro) form.
A provider may request a 2-week extension on a previously approved service by calling before the approval expires. Time extensions do not apply to initial window period.
Prior authorization instructions: Submit the prior authorization request in myWSI or complete the Prior Authorization Review Request (URC) form.
An evaluation is required prior to review for chronic pain program. Evaluation needs prior approval from the claims adjuster.
Prior authorization instructions: Referral required.
An evaluation may be performed without prior authorization.
To request additional services following the evaluation, submit the prior authorization request in myWSI or complete the Prior Authorization Review Request (URC) form.
A provider may request a 2-week extension on a previously approved service by calling before the approval expires.
Applicable Services: Arthrogram, Bone Scan, CT Scan, Discogram, MRI, Myelogram, PET Scan, Thermography
Prior authorization instructions: Submit the prior authorization request in myWSI or complete the Prior Authorization Review Request (URC) form.
CT scans performed within 30 days from the date of injury and directly related to the work injury do not require prior authorization.
All imaging listed in this section requires prior authorization unless the patient is admitted from the ER or is inpatient status.
Applicable Services: Gym Memberships, Aquatic/Pool Facility Membership
Prior authorization instructions: Submit the prior authorization request in myWSI or complete the Independent Exercise Program Request (C59a) form.
Applicable Services: Botox, Cryoablation, Epidural Steroid Injection, Facet Joint Injection, Facet Nerve Block (Medial Branch Blocks), Hyaluronic Acid Injection (Viscosupplementation), Peripheral Nerve Block, Platelet-Rich Plasma Injection, Radiofrequency Ablation (RFA)/Rhizotomy, SI Joint Injection, Spinal Nerve Block, Stellate Ganglion Block, Stem Cell Injection or Therapy, Sympathetic Nerve Block
Prior authorization instructions: Submit the prior authorization request in myWSI or complete the Prior Authorization Review Request (URC) form.
Prior authorization instructions: Submit the prior authorization request in myWSI or complete the Prior Authorization Review Request (URC) form.
Exceptions: See Prior Authorization Not Required.
Applicable services: Physical and Occupational Therapy, Home Health Care PT/OT
Prior authorization instructions: Submit the prior authorization request in myWSI or complete the Prior Authorization Review Request (URC) form after an initial or post-surgical window period of 10 visits or 60 days of care, whichever occurs first.
- An initial evaluation or re-evaluation visit is included in window periods.
- One initial window period is allowed per claim – not per body part or diagnosis.
- A limit of 2 modalities per visit is allowed during a window period.
- Treatment must start within 90 days after the surgery date for a post-surgical window.
To request more than 4 units of timed and/or non-timed care per visit, include the number of requested units per visit when submitting the prior authorization request in myWSI or complete the Prior Authorization Review Request (URC) form.
An evaluation/re-evaluation may be performed without prior authorization if there has been a lapse (greater than 2 weeks) in therapy services. To request continued therapy services, submit the prior authorization request in myWSI or complete the Prior Authorization Review Request (URC) form.
A provider may request a 2-week extension on a previously approved service by calling before the approval expires. Time extensions do not apply to initial or post-surgical window periods
Prior authorization instructions: Submit the prior authorization request in myWSI or complete the Prior Authorization Review Request (URC) form.
Prior authorization instructions: Submit the prior authorization request in myWSI or complete the Prior Authorization Review Request (URC) form.
A provider may request a 2-week extension on a previously approved service by calling before the approval expires.
Prior authorization instructions: Submit the prior authorization request in myWSI or complete the Prior Authorization Review Request (URC) form.
A psychosocial evaluation with standardized testing is required prior to review for spinal cord stimulator trial. The evaluation needs prior approval from the claims adjuster.
A post-surgical therapy window is not allowed
Prior authorization instructions: Submit the prior authorization request in myWSI or complete the Prior Authorization Review Request (URC) form.
An evaluation is required prior to review for vision therapy. The evaluation may be performed without prior authorization.
A provider may request a 2-week extension on a previously approved service by calling before the approval expires.
Prior authorization instructions: Submit the prior authorization request in myWSI or complete the Prior Authorization Review Request (URC) form.
A provider may request a 2-week extension on a previously approved service by calling before the approval expires.
Services Requiring Prior Authorization by Claims Adjuster
Prior authorization instructions: Provider must call for prior authorization.
Prior authorization instructions: Provider must call for prior authorization.
Emergent: No prior authorization is required
Applicable services: Chemical Dependency, Detoxification, Psychiatric Evaluations
Prior authorization instructions: Provider must call for prior authorization.
Prior authorization instructions: Provider must call for prior authorization.
Prior authorization instructions: An evaluation is required prior to review for chronic pain program. The evaluation needs prior approval from the claims adjuster.
Applicable services: Restorative fillings, crowns, bridges, and veneers; Dentures and implants, including partial or impartial and fixed or removable; All dental surgical procedures whether performed in the office or outpatient setting, including endodontics, periodontics, oral, and maxillofacial surgery
Prior authorization instructions: Submit the American Dental Association (ADA) Dental Claim form.
Prior authorization instructions: Provider must call for prior authorization.
See WSI's Durable Medical Equipment Guide.
Prior authorization instructions: Provider must call for prior authorization.
Prior authorization instructions: Provider must call for prior authorization.
WSI does not reimburse for an FCE/FCA performed by PTA, COTA, ATC.
Applicable services: Home health care, wound care
Prior authorization instructions: Provider must call for prior authorization.
Prior authorization instructions: Provider must call for prior authorization.
Prior authorization instructions: Provider must call for prior authorization.
Prior authorization instructions: Provider must call for prior authorization.
Prior authorization instructions: Provider must call for prior authorization.
Prior authorization instructions: A provider must call for prior authorization when the following criteria are not met
- One assessment is allowed every 2 weeks without prior authorization.
- Assessment must be scheduled within 2 days of an office visit.
- Utilized to accurately determine capabilities of the injured employee
- Warranted only if the injury results in job restrictions
- Requires a separate report, identifiable as the workability report, even if the assessment is completed on the same date as other therapy
Prior authorization instructions: Provider must call for prior authorization.
Services Not Requiring Prior Authorization
- Acupuncture: No more than 18 treatments may be paid over the life of a claim
- Angiogram
- Bronchoscopy
- CT angiogram
- Colonoscopy
- Cystoscopy
- Echocardiogram
- Electrodiagnostic study (EMG): Provider must be certified or eligible for certification by ABEM, ABPMR, AMNP
- EEG
- EKG
- Endoscopy
- Esophageal swallow study
- Hydrascan
- Indium scan for pain pump
- Indium scan for WBC check
- Joint injections: Refer to Services Requiring Authorization by UR
- Multi-Gated Acquisition (MUGA) scan
- Sleep study
- Stress test
- Splint fabrication and modification
- Tomogram (Unless ordered in conjunction with other imaging)
- Trigger point injections: No more than 20 injections may be paid over the life of a claim
- Upper gastrointestinal imaging
- Ultrasound
- Ultrascan
- Venogram
- Venous Doppler
- X-ray
- Acute bone grafting with ORIF (Includes 60 days from date of injury)
- Acute repairs (Includes 60 days from date of injury): Digital amputation; Digital and hand laceration; Digital and hand tendon/ligament; Digital and hand nerve; Digital and hand artery; Open or closed reductions
- Biopsies
- Carpal tunnel release
- Cataract surgery
- Cyst removal
- De Quervain's release (dorsal compartment release)
- Detached retina repair
- Foreign body removal
- Hardware removal
- Heart catheterization
- Hernia repair
- Neuroma excision
- Scar revision (Includes laser)
- Skin graft
- Trigger finger release
- Vitrectomy repair
- Wound irrigation and debridement (I & D) (A post-surgical therapy window is not allowed)
- Assistive device instruction (e.g., crutch care)
- Initial evaluation
- Isokinetic test (e.g., Biodex, Humac): 2 allowed during an episode of care
- Wound debridement and dressing change
Services Not Covered by WSI
- Acupressure
- ARP wave accelerated recovery performance therapy
- Athletic trainer services provided under agreement/contract
- Brain mapping utilizing EEG for neurofeedback
- Chemonucleolysis
- Continuous-flow cryotherapy unit
- Cupping
- Dry needling (and modalities used in conjunction with dry needling, i.e. electrical stimulation)
- Extracorporeal shock-wave therapy
- Injections: Colchicine except to treat an attack of gout precipitated by a compensable injury; Chymopapain; Fibrosing or sclerosing agents, except where varicose veins are secondary to a compensable injury; Injections of substances other than cortisone, anesthetic, or contrast into the subarachnoid space (intrathecal injections)
- Intradiscal electrothermal annuloplasty (IDET)
- Light therapy (cold laser therapy)
- Massage therapy unless provided by PT/OT or chiropractor in an active therapy plan
- NC stat and neurometric
- Prolotherapy (sclerotherapy)
- Reflexology
- Rolfing
- Spine strengthening program (e.g., MedX, SpineX)
- Surface EMG
- Vertebral axial decompression therapy (Vax-D treatment
Need help?
Utilization Review (UR) Department
Phone: 701-328-5990 or 888-777-5871
Fax: 701-328-3765 or 866-356-6433
Customer Service (Claims and Billing)
Phone: 701-328-3800 or 800-777-5033
Fax: 701-328-3820 or 888-786-8695