Quick answer
What this means in practice
Treatment disputes after 1 July 2026 should be prepared around the clinical reason for treatment, the accepted injury, alternatives tried, functional benefit and why the request is reasonably necessary in the worker's circumstances.
- A treatment request should answer why the treatment is needed, not only that the worker wants it.
- The accepted injury, current symptoms, failed conservative treatment and expected functional gain usually matter.
- Surgery, psychology, scans, physio and specialist reviews may each need different evidence.
- SIRA has flagged further consultation on reasonably necessary medical expenses, so these pages should stay under review.
What "reasonably necessary" usually turns on
In practice, the insurer is usually looking at whether the proposed treatment relates to the accepted work injury, is clinically justified, and is likely to help recovery, function, pain management or return to work.
The treating practitioner should explain the purpose of the treatment and why alternatives are not enough. A bare referral is often weaker than a short report that answers the insurer's likely objection.
Evidence to include with a treatment request
- Referral or request explaining diagnosis, accepted injury and treatment purpose.
- Clinical notes showing symptoms, restrictions, treatment tried and response.
- Imaging, specialist opinion or therapist reports where relevant.
- Functional goals tied to work, domestic tasks or rehabilitation progress.
- A current certificate of capacity if the treatment affects work restrictions or recovery at work.
- Written reasons from the insurer if the request is refused.
If treatment is refused
Ask for the refusal in writing and identify the reason. A refusal based on causation needs different evidence from a refusal based on clinical utility, cost, alternative treatment or an IME opinion.
The response should answer the stated reason with targeted treating evidence. If the dispute involves surgery or a major treatment step, the timing and evidence sequence should be checked before lodging broad material.
Official sources checked
This guide is based on SIRA and NSW Government sources available at the update date above. It is general information only and is not legal advice.
Frequently asked questions
Does a doctor referral mean the insurer must pay?
Not automatically. A referral helps, but the evidence should explain why the treatment is reasonably necessary because of the accepted work injury.
What if the insurer relies on an IME to refuse treatment?
Compare the IME opinion with treating evidence, accepted injury, imaging, symptoms and treatment history. The response should identify specific gaps rather than simply saying the IME is unfair.
Should I keep paying privately while a dispute runs?
That depends on the treatment, urgency, cost and dispute pathway. Keep receipts and get advice before assuming reimbursement will be available.
Need help applying this to a live claim?
If an insurer has issued a notice, scheduled an assessment, reduced payments, refused treatment, or raised the 2026 reforms in your claim, get the documents checked before the issue hardens.