Who can modify, delay and deny requests for treatment?

• A. Certified physician
• B. Licensed physician's assistant or nurse
• C. Licensed medical provider in that speciality
• D. Claims adjuster

Answer: (C)

The essential idea is that decisions about modifying, delaying, or denying medical treatment must come from someone with appropriate medical licensure and specialty training. A licensed medical provider in that specialty has the clinical authority to judge medical necessity, appropriateness, and safety of a proposed treatment. They review the patient’s condition, consult relevant guidelines or MTUS criteria, and determine whether a change in the plan is warranted, whether a delay is needed, or whether a requested treatment should be denied because it isn’t medically justified. This ensures that care decisions reflect clinical judgment rather than administrative rules.

A certified physician may not automatically carry this authority in every context, since licensure status and scope of practice matter. A licensed physician’s assistant or nurse can provide care, but they typically operate under physician supervision and within a defined scope, so independent modification or denial of treatment isn’t guaranteed in all situations. A claims adjuster handles the administrative side of the claim and does not determine medical necessity, so they aren’t the ones making these clinical decisions.