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Surgery Claim Denied. Next Steps? - Printable Version

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Surgery Claim Denied. Next Steps? - Clchew - 07-24-2013

Hello All,
12/26/2010 I injured my right hip at work. I was bending down loading something into a cart (I'm a flight attendant) and made a twist and heard and felt a pop in my hip. I filed my claim, went to the Dr. He diagnosed it as hip bursitis. I was taken off work for 2-3 months, given a series of cortisone injections, meds, patches and physical therapy. I'd researched bursitis and saw that it was one of those annoying lingering things so I pretty much managed it by restricting activities that would irritate my hip and taking ibuprofen and Tylenol. Not ideal but it kept the discomfort and pain bearable. Earlier this year, I noticed the pain was getting worse. Much worse. The pain was back to where it was when I initially got hurt. I was unable to sleep at night or do a lot of the things I was doing so I was able to get them to reopen my case. I was sent back to the Dr I saw 3 years ago, he did an X-ray, told me he saw some issues that concerned him, was removed me from work and said he was referring me out to an orthopedic surgeon. I was given a panel to choose from and went with the dr who had the best health grades and overall reviews. Fortunately, he's apparently "The" hip guy locally. He said he thought it was gong to be rather simple but upon looking at X-rays he sent me in for an arthrogram MRI. Having a long needle stuck into your hip socket is NOT fun! In the end he determined that I have a small bone spur on my hip (pre existing) but apparently that day at work, things just kinds lined up so that the bone spur came in contact with the labrum (cartilage) around the hip socket and tore it. Although the bone spur was preexisting, the fact is I could've went my entire life without it being an issue if it wasn't for this injury that clearly occurred as a result of doing my job. There really seem to be no alternatives to fixing this other than arthroscopic surgery to file down the bone and stitch up the cartilage. **no names please** had been so slow in responding (if responding at all) to my inquiries from the moment I requested to reopen my case (it took over 3 weeks of daily calls and emails before anyone got back to me and every step there after was rather drawn out) so I was eventually assigned a local case manager/worker. Things moved much smoother after that and at the last appointment when the dr recommended surgery she (thr case manager) basically told me she didn't see any issues, everything looked good and the causation and dr notes were very well written and to expect to have surgery at the end of this month (July). I thought that was it and made arrangements for friends to help me for the next month or so as I was told I'd be on crutches for 4-6 weeks and to stock up on reading material. Well, they denied my claim. I wasn't expecting that as the case worker seemed so confident that there would be no issues so my question is, is it just standard to automatically deny a claim? I will make an appointment with my dr today to discuss an appeal because he feels that w/o surgery, I'll be looking at an arthritic hip by 50 (I'm 38) and hip replacement soon thereafter. He flat out told the case worker that living with this is an unbearable situation for me to be in and it really is. I'm SOOOOO tired of hurting and taking pills that I don't know what to do! Also, is now the time to contact an attorney or should I sit to see the decision on the appeal.
Sorry so long and thanks in advance,
Chris


RE: Surgery Claim Denied. Next Steps? - 1171 - 07-24-2013

no it's not standard. each carrier, injury, and claim are different. thousands of claims every day are paid.
most states require that the denial be in writing and include the reason and directions for appeal.
each state has different comp laws.
most states require that such determinations be supported by medical evidence.
if you have medical evidence that supports that the aggravation is causing the need for treatment, you should appeal to your state's work comp board.
in the meantime your group health should pickup treatment until a coverage decision is made.