Overview
How this affects your claim in practice
Prior insurer approval is generally required before NSW workers compensation treatment is provided, unless section 60 or Part 4 of the Workers Compensation Guidelines creates an exemption. Initial treatment within 48 hours after the injury is one exemption. The Guidelines also contain conditional exemptions for particular treating-doctor, public-hospital emergency, specialist, imaging, pharmacy and approved allied-health services; each service, provider, timing and session condition must be checked.
An exemption from pre-approval does not make every cost payable. The service must still relate to the compensable injury, fall within the applicable section 59A period, be reasonably necessary under the law applying to the request, be provided by an appropriately qualified provider and satisfy fee and verification rules. Emergency care should be obtained when clinically required; preserve the records and notify the insurer promptly.
- A recommendation from a treating practitioner is important, but it should explain why this service is appropriate for this worker and injury.
- An alternative that may produce a similar outcome does not by itself make the recommended treatment unreasonable.
- Prior insurer approval is still generally required unless a legislative or Guidelines exemption applies.
- The section 59A treatment period, provider qualification, fee rules and proper verification remain separate requirements.
- The test changes to “reasonable and necessary” for new treatment claims made on or after 1 October 2026; earlier treatment claims retain the former test.
Practical review
What to check in this situation
- Identify the exact service and whether a current Guidelines exemption applies before assuming approval is unnecessary.
- Keep causation, reasonable necessity, prior approval, section 59A and provider or billing issues as separate questions.
- For emergency care, retain the triage time, injury history, ambulance or hospital record, referral and itemised account.
Records that may help
Keep the treatment request, referral, insurer approval or refusal, emergency and ambulance records, clinical notes, treatment plan, quote, invoices and evidence of the date each document was sent.
Next procedural step
For planned care, seek written approval unless a verified exemption applies. If treatment is urgent, prioritise clinical safety, notify the insurer and provider promptly, and obtain advice if payment is disputed.
The Guidelines require a claim-specific assessment
Part 4 of the SIRA Workers Compensation Guidelines states that treatment expenses are payable where they fall within section 59, are within the applicable compensation period, are reasonably necessary and have prior approval unless an exemption applies. Each element needs to be checked.
“Reasonably necessary” does not mean indispensable or the only possible treatment. The decision should consider the worker’s diagnosis, clinical findings, history, function, treatment response and proposed goals. It should not be reduced to a preference for the cheapest option.
Five factors used where necessity is unclear
The SIRA guidance expressly says that another treatment capable of producing a similar result does not, by itself, mean the recommended treatment is not reasonably necessary. The comparison still needs to address the circumstances, evidence, risks, cost and likely outcome.
The SIRA factors are applied together and in context. No single factor automatically decides the request.
| Factor | What useful evidence may address |
|---|---|
| Appropriateness | Diagnosis, clinical findings, contraindications, stage of recovery and why the service fits the worker’s condition. |
| Available alternatives | What has been tried, response, other options considered and why the recommended option is now proposed. |
| Cost | Quote, frequency, duration and whether the likely benefit is proportionate to the expense. |
| Actual or potential effectiveness | Past response, published clinical basis where relevant, measurable goals and a review or stopping point. |
| Acceptance by medical experts | Treating specialist reasoning, accepted clinical practice and any competing independent medical opinion. |
What a practitioner’s request should cover
A useful request is usually concise and clinically specific. It should allow the insurer to understand what is requested, why it relates to the accepted injury and how progress will be evaluated. Repeating a diagnosis without explaining function or treatment history may leave the central issue unanswered.
- Accepted injury and current diagnosis, including any disputed consequential condition.
- Relevant examination findings, imaging or test results without treating imaging alone as proof of need.
- Symptoms and concrete effect on work, mobility, self-care or rehabilitation tasks.
- Treatment already provided, frequency, duration, response and reason for changing course.
- Exact service, provider, timing, number of sessions or procedure requested and cost.
- Expected outcome, functional goal and when the treatment will be reviewed.
- Alternatives considered and the reason they are unsuitable, exhausted or less appropriate.
- Any treatment risk, comorbidity or capacity issue relevant to the recommendation.
Different services need different supporting detail
| Request | Examples of service-specific evidence |
|---|---|
| Surgery | Surgeon’s diagnosis, procedure, relationship to injury, conservative treatment, alternatives, expected benefit, risks and post-operative rehabilitation plan. |
| Psychological treatment | Diagnosis, relationship to the accepted injury, treatment plan, frequency, goals, progress and coordination with work capacity. |
| Physiotherapy or other allied health | SIRA provider status, Allied Health Treatment Request where required, baseline function, progress, home plan and measurable goals. |
| Imaging | Clinical question the scan is intended to answer, relevant findings and whether the referral fits a Guidelines exemption. |
| Medication | Indication, response, adverse effects, monitoring and whether the item falls within the pharmacy exemption conditions. |
Necessity and prior approval are separate questions
Even clinically justified treatment ordinarily needs prior insurer approval. The Guidelines provide limited no-preapproval pathways, including initial treatment within 48 hours and specified short periods for nominated treating doctors, public hospital emergency departments, referred specialists, imaging, pharmacy and SIRA-approved allied health.
The detailed conditions in Tables 4.1 and 4.2 matter. For example, allied-health exemptions depend on provider approval, how long after injury treatment begins, session limits and, in some circumstances, an Allied Health Treatment Request and insurer response.
Match the response to the refusal reason
A causation refusal is different from a necessity refusal. An approval or billing problem is different again. Before gathering more evidence, identify every reason in the insurer’s written decision and the material relied upon.
- Connection: medical reasoning linking the service and condition to the accepted work injury.
- Necessity: treatment history, alternatives, clinical purpose, expected benefit and expert support.
- Prior approval: approval records or the exact Guidelines exemption and conditions relied upon.
- Section 59A: claim date, weekly-payment history, WPI category and any statutory exception.
- Provider or fee: qualifications, SIRA approval, fee-order compliance, codes and invoices.
- Verification: itemised accounts, dates, referrals and proof that the service was supplied.
Do not apply the October 2026 test early
From 1 October 2026, the statutory expression changes from “reasonably necessary” to “reasonable and necessary” for treatment claims made on or after that date. A claim for treatment made before commencement remains under the former law, whether already approved or still pending.
The new expression should not be inserted into a July or August decision as though it had commenced. After October, the treatment-request date should be recorded before deciding which test applies.
Official sources
Sources are listed for transparency. This guide is general information only and is not legal advice.
- Workers Compensation Act 1987 (NSW), sections 59, 59A and 60
- SIRA Workers Compensation Guidelines in force from 1 July 2026, Part 4
- SIRA: reasonably necessary treatment, updated 1 July 2026
- SIRA: 2026 reforms information for health providers
- SIRA Standard S15: treatment approval and payment
- Personal Injury Commission: 1 October 2026 medical-expense change
Frequently asked questions
Does “reasonably necessary” mean the treatment must be essential?
No. SIRA states that reasonably necessary does not mean absolutely necessary. The assessment is practical and case-specific.
Can the insurer refuse treatment because another option is cheaper?
Cost and alternatives can be relevant, but SIRA says an alternative capable of a similar result does not by itself make the recommended treatment unreasonable. The whole clinical and factual context should be considered.
Is a specialist recommendation enough?
It is important evidence, but the report is more useful if it explains injury connection, findings, earlier treatment, alternatives, expected benefit, risks, cost and review points. Other statutory requirements still apply.
Do I need prior insurer approval?
Usually yes. Limited exemptions appear in the legislation and Part 4 of the Guidelines. The exact service, timing, provider and session conditions need to be checked.
When does “reasonable and necessary” begin?
It begins for new treatment claims made on or after 1 October 2026. Treatment claims made before commencement retain the current “reasonably necessary” test under the transitional provision.
Need a treatment refusal matched to the evidence?
Provide the request, insurer reasons, accepted-injury material, treating reports and any IME opinion. The next step should answer the actual legal and clinical issue, not simply add more pages to the file.