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And The Fight Begins.... NY
#1
The Insurance Carrier is really ticking me off....   Contacted my lawyer and told him I haven't heard anything from Comp for a hearing and asked if he got the papers I sent to him from my new surgeon...

Well, he says Comp will NOT do a hearing because the MG-2 papers are being sent to the wrong place..  

HOW????   

I have copies of the ones from 2 different surgeon's offices and from pain management... all sent to the exact same place since this all started in 2012.. all using my Claim Number and WCB number..  All being signed by the Carrier's Adjuster/Examiner that is handling my case and is putting them NOT MEDICALLY NECESSARY... and their UR doctor is signing and dating them too... As they put it, they will not approve a MRI just for pain...  It's not just pain.. they want to see how much worse those disc have gotten.. Yes, both legs have been going numb, but the right leg, hip and the entire lower back is about gone...

There has never been a problem sending any request for a procedure until we settled the work part of it.

I sent my new surgeon a message to see if he can send in a third request to the exact same fax we were all given and to send a copy if it to my lawyer...   I just don't know what else to do but nail them good for a medical settlement...

And they wonder why injured workers suffer with stress and depression...
 
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#2
The system does not do well with serious longstanding medical conditions.
Reminder :
........Each state has their own comp system; POST YOUR STATE to get accurate information. Use the search feature to find information from similar questions.
THANKS FOR POSTING.
 
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#3
The carrier in my case moved from NY to NJ changed their phone number and fax number and never notified workers comp or anyone else. It took months for me to get an approval for a procedure. Good luck hopefully everything works out for you
 
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#4
Surgeon's office faxed request #3 yesterday and got the denial today... so all that was faxed to my lawyer... Comp tries to tell us it's being sent to the wrong place again, I don't know what else to do but demand a hearing....
 
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#5
Try certified mail or priority mail express....
Reminder :
........Each state has their own comp system; POST YOUR STATE to get accurate information. Use the search feature to find information from similar questions.
THANKS FOR POSTING.
 
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#6
Try certified mail or priority mail express....
Reminder :
........Each state has their own comp system; POST YOUR STATE to get accurate information. Use the search feature to find information from similar questions.
THANKS FOR POSTING.
 
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#7
Paper from Comp arrived yesterday...

FINDINGS: The MG-2 variance request received by the Board on 6/13, seeking approval of a lumbar spine MRI, is denied. There is no medical evidence of progressively worsening symptoms and/or neurological deficit. There is insufficient medical provided to support the request, the provider did not meet the burden of proof and failed to support the need to vary the guidelines.
No further action is planned by the Board at this time..

So.... I'll bring that paper with me on the 26th and have a nice chat with my new surgeon about it and see what he can do to prove there is more damage and problems... if he can't.. and Comp & the IC will just deny everything, meeting with my lawyer will take place and see about closing out medical. Cause if everyone is saying there's nothing wrong, nothing more we can do, no surgery, etc... then why keep it open.....
 
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#8
I recommend getting a copy of your doctors request for MRI. Sometimes doctors do not write the things needed to get an approval. If your doctor is not making requests that include reasons for the request that coincide with medical treatment (sometimes bull crap) guidelines the insurance carrier uses, then you will not get things approved. You would be surprised how many doctors don't do this, or know how.

I would close out medical if you have other insurance that covers it.(JMO)
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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#9
He posted on the Patient Portal... same with the MG-2.. and the Denial...

He has listed there is 4 discs involved (not 1), listed the pinched nerves are causing more problems with both hips, numbness down both legs, burning & tingling down both legs, the fall down the cellar stairs due to legs giving out, if this continues, I'll be in a wheelchair due to the damage not being fixed.... And they still deny procedures... Biggie with the MRI is to compare it to one taken in 2017 and prove there is more damage.. They'll pay for an x-ray but that doesn't show nerves... wonder if he put in for a EMG for lower back/tailbone area if they'll approve that....
 
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#10
(06-24-2019, 07:37 AM)tbear6410 Wrote: He posted on the Patient Portal... same with the MG-2.. and the Denial...

He has listed there is 4 discs involved (not 1), listed the pinched nerves are causing more problems with both hips, numbness down both legs, burning & tingling down both legs, the fall down the cellar stairs due to legs giving out, if this continues, I'll be in a wheelchair due to the damage not being fixed.... And they still deny procedures... Biggie with the MRI is to compare it to one taken in 2017 and prove there is more damage.. They'll pay for an x-ray but that doesn't show nerves... wonder if he put in for a EMG for lower back/tailbone area if they'll approve that....

So sorry for what you are going through.

I am not familiar with your states utilization review process. I am trying to understand why the heck your treatments are getting denied. In my state doctors who include information in the patients records but do not include it in the treatment request often times get denied. In fact I believe this is the number one reason why treatment is denied in my state. The utilization review doctors do not get sent the patient entire file and usually only review the treatment request and sometimes the last 6 months of records. I don't know if this type of thing is happening with you, but it is VERY common here in California. UR doctors receive a request for MRI for example and the request does not give any reason for it or treatment guidelines, or enough reason.

I trust doctors, but verify by requesting the request they sent to the insurance carrier. I found often times they are not requesting the test or treatment with any backup. Again, I don't know if this is happening in your case, just wanted to mention, and also mention UR doctors usually do not go through patients entire medical file. They usually do high volume UR's and spend bare minimum on them from what I have read. Treatment requests need to contain everything needed (insurance carriers song and dance info they require to get authorization). I
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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