NYS Workers Comp Physical Therapy Guidelines: Limits and Variances

Physical therapy under New York workers’ compensation is governed by the state’s Medical Treatment Guidelines, a set of mandatory, evidence-based protocols the Workers’ Compensation Board uses to pre-authorize care within defined frequency and duration limits. The NYS workers’ comp physical therapy guidelines cover 16 categories of injury and condition, and treatment that stays within the applicable guideline does not need individual approval from the insurance carrier. Anything beyond those limits requires a formal variance request, and continued authorization at every stage depends on documented, objective functional improvement.

Which Injuries the Guidelines Cover

The Medical Treatment Guidelines are codified at 12 NYCRR § 324.2 and require every treating provider to follow the applicable protocol. There are currently 16 guidelines:

Musculoskeletal: ankle and foot, elbow, hand/wrist/forearm, hip and groin, knee, mid and low back, neck, and shoulder
Pain and neurological: complex regional pain syndrome, non-acute pain, and traumatic brain injury
Psychological: post-traumatic stress disorder, acute stress disorder, and work-related depression
Respiratory: occupational interstitial lung disease and work-related asthma
Vision: eye disorders

If your injury falls under one of these categories, your provider’s treatment plan must follow the corresponding guideline. The version in effect on the date of treatment controls, not the version that existed on the date of injury.¹ For body parts or conditions that don’t yet have a specific guideline, the Board’s fee schedule ground rules govern treatment frequency and duration instead.²

Choosing Your Physical Therapist

Under Workers’ Compensation Law § 13-a, you have the right to choose any physical therapist authorized by the Workers’ Compensation Board. Your employer, their insurance carrier, and any third-party administrator cannot direct you to a specific provider or interfere with your choice, and doing so is a misdemeanor.³

There is one exception. If your employer participates in a Preferred Provider Organization or an alternative dispute resolution program, you may be required to see a provider within that network for the first 30 days of treatment. After that period, you can switch to any Board-authorized therapist. You can confirm authorization status through the search tool on the Board’s website.⁴

How Treatment Starts

Physical therapy in the workers’ comp system requires a prescription or referral from an authorized physician, physician assistant, podiatrist, or nurse practitioner. A physical therapist cannot independently initiate treatment. Both the referring provider and the treating therapist must hold Board authorization, and both must keep records of the patient’s condition, progress, and treatment instructions.⁵

At the first visit, the therapist takes baseline measurements: range of motion, muscle strength ratings, pain levels, and the ability to perform specific physical tasks. Everything that follows depends on these numbers. Continued authorization requires showing measurable improvement from the baseline, and vague or incomplete starting data makes it easy for a carrier to challenge later requests for more sessions.

Frequency and Duration Limits

Each guideline sets its own frequency and duration limits tuned to the typical healing trajectory for that body part. Treatment inside those limits is pre-authorized; treatment beyond them requires a variance.

The Mid and Low Back Injury guideline is a useful example. It recommends two to three visits per week for the first two weeks to establish an exercise program. Total visits can range from as few as two or three for mild injuries up to 12 to 15 when the provider documents objective functional improvement along the way.⁶ Other body parts have different parameters, so your therapist should be working from the specific guideline for your injury.

Providers are expected to evaluate whether treatment is working: two to three weeks after the initial visit, then every three to four weeks after that. If treatment isn’t producing measurable results, the provider should change the approach, reconsider the diagnosis, or discontinue the intervention rather than keep billing for sessions that aren’t helping.⁷

Documenting Functional Improvement

Keeping treatment authorized past the first few visits depends entirely on documenting objective functional gains. The Board defines these as measurable improvements in physical capacity that connect to your ability to perform daily and work activities. Subjective reports that the patient “feels better” carry almost no weight.

Acceptable functional gains include improvements in positional tolerance (sitting, standing, or walking for longer durations), increased range of motion measured in degrees, higher strength ratings, better endurance, and greater independence with daily living tasks.⁷ The therapist should tie the numbers to real-world function. A five-degree gain in shoulder flexion documents progress, but is more persuasive paired with a note that you can now reach the overhead shelves your job requires.

Without this evidence, the carrier can legally deny payment for further sessions on the grounds of insufficient medical necessity. Many claims run into trouble here: therapists who track gains informally but don’t record them in the format the system expects can inadvertently cut off their patient’s coverage.

Getting Sessions Beyond the Guideline Limits

When you need treatment beyond what the applicable guideline recommends, your provider submits a Prior Authorization Request (PAR) through the Board’s OnBoard electronic portal. Electronic submission replaced the paper Form MG-2, which the Board stopped accepting on May 2, 2022. Paper forms cannot be faxed, emailed, or mailed.⁸

The PAR must include clinical documentation justifying why additional care is necessary: progress notes, treatment history, and evidence of functional improvement from the sessions already completed.

Deadlines and Automatic Approval

The carrier has 15 calendar days to respond to a PAR. If the carrier wants an independent medical examination (IME) before deciding, it must notify the provider within five business days of receiving the PAR, which extends the response deadline to 30 calendar days.⁹

If the carrier fails to respond within the applicable deadline, the variance may be deemed approved on the ground that approval was unreasonably withheld. The Board will issue an order confirming the approval, the carrier faces a penalty under Workers’ Compensation Law § 25(3)(e), and that order is not appealable.⁹ Carriers know this and rarely miss the deadline outright. More often they deny the request with a specific medical reason, which starts the dispute process.

When a Variance Is Denied

If the carrier denies the PAR, the provider or the injured worker can file a Request for Further Action (Form RFA-2) to bring the dispute before the Board.¹⁰ If administrative resolution fails, the matter goes to a formal hearing before a Workers’ Compensation Law Judge, who reviews the medical evidence from both sides and issues a binding decision.

When the denial is coded “Denied – IME Related” in OnBoard, meaning it turned on an IME scheduling issue rather than a substantive medical determination, it cannot be escalated for review directly. The provider can submit a new PAR for the same treatment, but a fresh submission restarts the clock and can trigger another IME request. If you’re scheduled for an IME, bring copies of your treatment records and expect a physical examination by a physician you have not seen before.¹¹

When Physical Therapy Ends

Physical therapy doesn’t continue indefinitely. At some point the treating provider determines that you’ve reached maximum medical improvement (MMI), meaning your condition has plateaued and further significant improvement isn’t reasonably expected within the next year, with or without continued treatment.¹² MMI doesn’t mean you’re fully recovered. It means you’ve recovered as much as you’re going to.

Once MMI is established, your provider assesses whether you have any permanent loss of function in the injured body part. If you do, you may be eligible for a Schedule Loss of Use award, which compensates you based on the percentage of function permanently lost. The provider submits a medical report following the Board’s Permanent Impairment Guidelines detailing the examination findings and the calculated percentage.¹³ This evaluation directly determines the amount of the award.

Maintenance Care After MMI

Reaching MMI doesn’t always end physical therapy. In limited circumstances the Board permits an ongoing maintenance program to keep your functional status from deteriorating. To qualify, you must meet all three of the following:

Permanent disability at MMI
Chronic pain that persists beyond the normal healing period
Documented functional decline when treatment was previously discontinued

The third element is the one that gets scrutinized. Your records must show a specific, objective decline in your abilities after treatment stopped, proving the maintenance sessions are preventing measurable regression rather than simply providing comfort.¹⁴ Maintenance programs can include physical therapy, occupational therapy, or spinal manipulation depending on the body part involved.

Bill Payment and Travel Reimbursement

Under Workers’ Compensation Law § 13-g, the carrier has 45 days after receiving a medical bill to either pay it or notify the provider in writing that payment is being withheld and explain why. If the carrier does neither, the provider can ask the Board to issue an award ordering payment, which triggers a $50 penalty against the employer and potential interest of up to 1.5% per month payable to the provider.¹⁵ Failure to pay an amount that has been formally awarded triggers stiffer penalties, including a 20% surcharge on the unpaid amount for the injured worker.¹⁶

You are also entitled to mileage reimbursement for travel to and from appointments. For 2026, the rate is 72.5 cents per mile.¹⁷ Track your mileage from the first visit and submit Form C-257 to your carrier. Many workers don’t realize this benefit exists, and the unreimbursed cost adds up quickly when you’re attending several sessions each week.

Records to Keep, and One Important Limit

One boundary in the system is worth knowing before you rely on your therapist’s notes. A physical therapist’s records and opinions cannot be used as evidence of whether your condition is causally related to your workplace injury, and cannot serve as evidence of disability. Only a physician can provide that documentation.⁵ Keeping your referring physician involved throughout treatment is legally necessary to preserve your claim.

From the first appointment forward, keep copies of your referral, every progress note, each baseline and follow-up measurement, any variance requests and carrier responses, IME reports, and your mileage logs. If a dispute reaches a hearing, organized records are what separate a strong case from an uphill one.

1
Legal Information Institute. N.Y. Comp. Codes R. & Regs. Tit. 12 324.2 – Medical Treatment Guidelines
2
New York State Workers’ Compensation Board. NYS Official Workers’ Compensation Physical and Occupational Therapy Fee Schedule Ground Rules
3
New York State Senate. New York Workers’ Compensation Law Section 13-A – Selection of Authorized Physician by Employee
4
New York State Workers’ Compensation Board. How to Become a NYS Workers’ Compensation Board-Authorized Provider
5
New York State Senate. New York Workers’ Compensation Law Section 13-B
6
New York State Workers’ Compensation Board. Mid and Low Back Injury Medical Treatment Guidelines
7
New York Workers’ Compensation Board. Medical Treatment Guidelines for Providers Seeking Board Authorization
8
New York State Workers’ Compensation Board. OnBoard – Health Care Providers
9
Legal Information Institute. N.Y. Comp. Codes R. & Regs. Tit. 12 324.3 – Variances
10
New York State Workers’ Compensation Board. Workers’ Compensation Board Common Forms
11
New York State Workers’ Compensation Board. Training – Health Care Providers Independent Medical Exam Request Notification
12
New York State Workers’ Compensation Board. Workers’ Compensation Guidelines for Determining Impairment
13
Workers’ Compensation Board. Understanding Your Schedule Loss of Use Award
14
New York State Workers’ Compensation Board. Medical Treatment Guidelines Frequently Asked Questions
15
New York State Senate. New York Workers’ Compensation Law 13-G – Payment of Medical Bills
16
New York State Senate. New York Workers’ Compensation Law Section 25 – Compensation, How Payable
17
New York State Workers’ Compensation Board. Mileage Reimbursement Rates