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surgery denied - deez - 04-26-2019

I live in Memphis tn. I have a work related injury it has been filed under workers comp ,I have a lower back lumbar /spin issue my doctor recommends surgery sense the other procedures didn't work well the surgery was denied due to lack of information the doctor submitted so at this point I am trying to find out what should do.


RE: surgery denied - 1171 - 04-26-2019

Sounds like a utilization review issue. You can talk to the doctor about providing necessary information that might get the decision changed or you can appeal the denial or get a doctor that knows how to work with workers com requirements.
More information on UR here
https://www.state.tn.us/workforce/injuries-at-work/bureau-services/bureau-services/medical-programs-redirect/utilization-review.html


RE: surgery denied - deez - 04-26-2019

(04-26-2019, 02:03 PM)1171 Wrote: Sounds like a utilization review issue. You can talk to the doctor about providing necessary information that might get the decision changed or you can appeal the denial or get a doctor that knows how to work with workers com requirements.
More information on UR here
https://www.state.tn.us/workforce/injuries-at-work/bureau-services/bureau-services/medical-programs-redirect/utilization-review.html

thanks, do you think I will need an attorney if the appeal is needed


RE: surgery denied - 1171 - 04-26-2019

(04-26-2019, 02:08 PM)deez Wrote:
(04-26-2019, 02:03 PM)1171 Wrote: Sounds like a utilization review issue. You can talk to the doctor about providing necessary information that might get the decision changed or you can appeal the denial or get a doctor that knows how to work with workers com requirements.
More information on UR here
https://www.state.tn.us/workforce/injuries-at-work/bureau-services/bureau-services/medical-programs-redirect/utilization-review.html

thanks, do you think I will need an attorney if the appeal is needed

Per the link I posted the appeal only requires the filing of the form. If you don’t want to do it yourself you can pay an atty to do it for you.


RE: surgery denied - 1171 - 04-26-2019

P.S. You should have gotten the form with the written denial.


RE: surgery denied - California_Help - 04-26-2019

(04-26-2019, 01:50 PM)deez Wrote: I live in Memphis tn. I have a work related injury it has been filed under workers comp ,I have a lower back lumbar /spin issue my doctor recommends surgery sense the other procedures didn't work well the surgery was denied due to lack of information the doctor submitted so at this point I am trying to find out what should do.

If it is a lumbar fusion he is recommending...I recommend getting a few other opinions before you decide to do it. Studies have shown it is no more effective than physical therapy. For some there is improvement but for others it can make them worse. Also, with a fusion there is a high chance of needing additional surgeries as the discs above and below can be affected from the fusion.


RE: surgery denied - California_Help - 04-26-2019

1171 do all states have utilization review and their own treatment guidelines? I ask because I just came across New York's the other day.


RE: surgery denied - 1171 - 04-26-2019

(04-26-2019, 07:28 PM)California_Help Wrote: 1171 do all states have utilization review and their own treatment guidelines? I ask because I just came across New York's the other day.

No. But business interests have put together a package with everything a state needs—including legislative wording to make sure that a particular state becomes more “ business friendly” then their neighbors by reigning in too high work comp premiums. It also comes with an ad campaign to drum up voter support. It’s difficult for worker supported legislators to overcome his onslaught. So most states have gone over. It’s very ironic because it is the medical industries greed that skyrocketed the costs in the first place.


RE: surgery denied - California_Help - 04-27-2019

I can understand why they use medical treatment guidelines (the states that do), however many doctors are not aware of them or do not review or use them in their requests. Some UR companies are looking for ANY reason to deny a request, even if it is due to a doctor not listing everything the guideline expects. For example a request for treatment or a test for a patient who has been in the system for years could be denied because the doctor failed to write physical therapy was tried previously. If a patient has a serious condition and has been in the WC system for years, chances are they have had physical therapy. This is one example. Another example for repeat SI injections and the requesting doctor wrote the patient states 60% pain relief but the UR reviewer denies citing the guideline that says patients must have 70% pain relief previously. What the heck!

This is the unfortunate pattern I see going on here in California. And my limited experience with IMR is IMR reviewers many of them deny a request even when the request includes everything that is needed for approval, they just ignore it. I read a few articles that they are looking into the group of doctors who are requesting a lot of IMR's. I have no idea why they would do that. Many physicians and applicant attorney's automatically send in the IMR every time UR denies something. The problem is this is often times not done with a letter or report that addresses the reasons for the original UR denial. And for the few who are submitting it, they soon find unlike UR, many IMR doctors don't read or ignore what was sent it.

IMR in California is anonymous and I believe this causes some/many physician reviewers to take advantage of the system and not review the records sent. The more reviews they do, the more $$$ they make so it is a numbers game.They need to change this and make them submit their name with the IMR. (IMO) There is no good reason why IMR reviewers need to be anonymous.

Sorry about my rant, but the system in California has lead to both over-treatment and under- treatment for injured workers as other entities are taking advantage. Injured workers should receive appropriate treatment. Adding layer upon layer of middle men and review systems for profit causes harm. Harm to injured workers, employers and society.


RE: surgery denied - 1171 - 04-28-2019

I believe our overall health care system is seriously flawed. It forces these bureaucratic complicated “wack-a-mole” type work arounds to keep the damn thing functioning even marginally.
Just look at the complexity of MSAs. Unifying our medical treatment system into one overall basic coverage plan would remove the need for much of the legal wrangling over approvals, lability hair-splitting, and cost controls. Those damn $$ issues are destroying care quality.