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prescription denied please help
#1
Hi all,
It's my first time in this forum, sorry first for any error. State is CA, my pain medication, NORCO, which had been prescribed by my PTP for more than a year, recently being denied by UR and upheld by IMR after my attorney's appeal. The doctor normally prescribed 120 units per month for my herniated disc, rotator cup tear, tennis elbow, neck sprain, because the pain was incredible! Now I have to pay out of my pocket for the med. The Attorney said there is nothing they can do, it's final. Is this true? FYI, I used to take 3 to 4 units a day, but since I was provided home therapies, and other outpatient treatments, I only take 1 or 2 a day. 
Thank you for your help!
 
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#2
I agree with your attorney there is nothing he can do.

I disagree that it is final. The IMR determination stands for 12 months UNLESS there is a change in condition or material facts in the claim that were not provided to UR or IMR. A change in condition can be an increase in pain, for example. Most people have an increase in pain if their medications are stopped.Your doctor can re-request the medications before the 12 month period if you have a change of condition and there is a box on the RFA form to check this off.

 If you do not have a change of condition you can review the information sent to UR and IMR. If there are relevant records that were not sent then this may be cause for your doctor to request the medication before the 12 month period.The UR denial and IMR denial should have listed the records sent. Review what they wrote as far as your condition...does it appear like the reviewers were sent records that reflect all of your injuries? Also, did the IMR doctor deny the medication without any refills or did he deny but recommend your doctor wean you off?

I responded on the other post you wrote in more detail.

If you do fall into a category above, you may be subject to UR again so it is important you review the reason(s) why they are denying your doctor requests. Hopefully you are at a doctor who will appeal UR denials when you get them and who writes reports with guidelines and rational that backs up his requests. Have you discussed this denial with your doctor? I also hope you are not treating at an industrial or mill as both can be bad for different reasons.
I am not an attorney.Anything I write should not be considered legal advice.I am writing from my own personal experiences,which is not from any sort of legal background. You should consult with an attorney over legal issues. In California, if you cannot get an attorney you can consult with an I&A officer.
 
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#3
Thank you for your response! You are right, I need to go back to check the denial from the UR and the IMR, then discuss with the Doc. He just told me that it was denied and told me "go talk to my lawyer"! No, the Doc has his own clinic and bunch of people working under him.
Thanks again!
 
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#4
Also most UR companies have an internal UR appeal process outside of IMR. This is where you or your doctor can appeal it through the UR company if they were not provided with information. I suggest reading each page of your UR denial to see if they have an internal review process for next time this happens.

Often times they deny something due to lack of information.

Another option is to talk to your doctor about alternatives and possibly to try another type of medication such as anti-inflammatory, or nerve pain medication (if he feels you have nerve pain issues). It sounds like you have been provided with alternative treatment options such as tens unit etc and this is more than what many patients are receiving.

I personally think it is good you lowered your dose for this on your own as this medication can carry bad side effects that can cause additional problems. If you are in severe pain that is not healthy either. Unfortunately opioids were being overly prescribed and part of the reason why they changed the laws in our state (and to save insurance companies money). For those who have severe injuries and truly need the medications to relieve the effects of their injuries this system is causing patients to pay for it themselves, use other insurance or do without.
I am not an attorney.Anything I write should not be considered legal advice.I am writing from my own personal experiences,which is not from any sort of legal background. You should consult with an attorney over legal issues. In California, if you cannot get an attorney you can consult with an I&A officer.
 
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#5
I sincerely thank you for your help! I just post another question in the forum, whenever you have a chance please run by it and input if any.
 
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#6
You are welcome.

I gave you a lengthy reply. You need to contact your attorney and ask what can he do about the denied body part. He can depose the doctor or ask your PTP to write a rebuttal and take the evidence to a judge. My responses are based on my limited knowledge of the system, and I am just an injured worker like yourself and not a professional. Your attorney would know the best strategy for moving forward.

Best of luck to you.
I am not an attorney.Anything I write should not be considered legal advice.I am writing from my own personal experiences,which is not from any sort of legal background. You should consult with an attorney over legal issues. In California, if you cannot get an attorney you can consult with an I&A officer.
 
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