[California_Help]

(05-31-2017, 05:27 AM)1 Hurt nurse Wrote: Thanks! I tried to PM you my email address but I don't think it went through.
The only things I see on the treatment guidelines for lower back and neck injuries are acupuncture and opioids. Seems very bleak.
The treatments that are helping me are rolfing, pilates and chiropractic. They were specifically recommended by my QME. I can start seeing an acupuncturist if you think they will cover it. Do you think there is a way to get my current treatments covered? I am happy to copy and paste my last QME report if that would help.

I will check to see if I can get into my pm.

If you are looking only at the MTUS and chronic pain guidelines those can be very limiting. You can also use ODG and OCOEM 2nd edition and I have gone outside and used other treatment guidelines and peer reviews if the condition or the request does not fall under listed guidelines. Never limit yourself to guidelines, especially MTUS.

There is a cap in California for chiropractic treatment. If you have had 24 it will be extremely difficult to get more approved.

Acupuncture can be approved and also sometimes Pilates. There are caps to acupuncture. If you can do Pilates I highly suggest continuing if your doctor has recommended it and you can tolerate it. Pilates and yoga can be a way out of chronic pain, you need a strong will and be extremely careful to not reinjure yourself. Have you had regular physical therapy by a licensed physical therapist? Is your injury to neck and lower back? I ask this because I need to know the body part to look up appropriate guidelines for you.

I would be hesitant to paste your QME report on public site. Hopefully pm is working.

I want you to review this IMR denial for acupuncture. Make sure your doctor makes a request for the initial 3-6 sessions for example. If your doctor used the MTUS guidelines, he would have to state you are using it with rehabilitation exercise pilates and you either cannot tolerate or have reduced medication. This is if you used this guideline.
file:///C:/Users/Owner/AppData/Local/Microsoft/Windows/INetCache/IE/3J7ZA45B/CM15-0027832.pdf

This is an IMR that approved request for continued acupuncture. You can see how the reviewer layed it out and explained why the request was warranted and quoted the guideline. Your doctor should be doing the same when he makes a request. You can also try to do it during an internal UR appeal or IMR, but easier when the doctor does it.
file:///C:/Users/Owner/AppData/Local/Microsoft/Windows/INetCache/IE/UJ0Z50K2/CM13-0031267.pdf

Another example for low back for your review.
file:///C:/Users/Owner/AppData/Local/Microsoft/Windows/INetCache/IE/4W4LO7LB/CM15-0023185.pdf

Whoever this IMR reviewer was, I like his ?
file:///C:/Users/Owner/AppData/Local/Microsoft/Windows/INetCache/IE/Q8HP2EP2/CM14-0216393.pdf

This IMR reviewer approved acupuncture for lower back and cervical spine and used ODG guidelines. It is important you list both if you need acupuncture for both. In these reviews records are included. Your doctor may have to send relevant records unless he includes the relevant information in his report.

file:///C:/Users/Owner/AppData/Local/Microsoft/Windows/INetCache/IE/3J7ZA45B/CM14-0176753.pdf

[California_Help]

I could not send a pm or access any private messages.

[California_Help]

You will need to cut and paste the links I provided to your search bar to view.

[California_Help]

To get things like gym memberships or Pilates and yoga approved you will need to put in some effort. You will need to overcome three objections used regularly that is the need for equipment and also you may need to show your therapy will be monitored and supervised by your doctor, and finally that you have attempted home exercise and it did not help.

In a request for Pilates year membership I recommend stating you need special equipment to rehabilitate. Denials are often based upon not needing special equipment, and also not being monitored by a licensed therapist or physician. One way to overcome a denial based upon you will not be monitored is to print out a list of exercises you will be doing, and for each exercise the duration or amount of reps. I have provided picture print outs as well taken pictures of the exercise (did not show face of person on picture) and next to it list what exercise and number of reps. Have your doctor look at the exercises and make note and have him keep track of your progress by doing things like ROM and pain scale tests. He can state he will be monitoring your progress. I recommend turning in the exercise packet to utilization review. Your doctor also has to state you have previously attempted home exercise and it did not help (if you have).

It is very difficult to get approved for these things but with effort I have seen it done. This is a boilerplate example of the guideline used to deny Pilates. A patient could in turn use the same guidelines as a means to approve it.

file:///C:/Users/Owner/AppData/Local/Microsoft/Windows/INetCache/IE/UJ0Z50K2/CM15-0066128.pdf

[California_Help]

(05-30-2017, 06:13 PM)1171 Wrote: Yup. The updates and fixes are coming very slow. The site has been in "excuse my dust" mode for last couple years. If it takes any longer it may be too dead to matter. i'm just about done with it myself; just too broken to hang around waiting.
I'm thinking I'll just post a few of the most helpful links for those that may wander by and hope they help.
This is one of the only sites not run by a law firm that refers everyone with question to an atty.
Admin/ Bob said a couple weeks ago to be patient as they are working on it........

1171,

I hope it gets fixed and you will continue to post. You are the person who answers the questions for many injured workers all over the country. I think I have seen you on another site a few years back that you and I no longer post on. My guess, you have helped thousands of injured workers. There are not many who volunteer their time anonymously. It takes a certain type of person.

[1 Hurt nurse]

Hi!
So my lawyer and the workers comp lawyer couldn’t agree on a settlement so we are going to trial Monday morning. My lawyer says there’s nowhere to go but up since he feels my QME rating was too low but the defense attorney is intimidating and unreasonable. I have no idea what to expect. My total rating so far for back and neck was 12% which equals about $29,000 in PPD. Defense offered $60,000 minus what I’ve received in PPD and $5000 less for overpayment of SDI but my lawyer says that not enough. What is an average payout for a lower back and neck injury for a nurse in California? Is there such a thing? Also, I live out of network now and have been unable to get insurance to send paperwork for approved therapy or a change in doctors. Since I have a lawyer now I am unable to contact my adjuster directly and their lawyer just ignores everything. I think settling is the best so I can get the help I need but don’t want to regret anything since my back seems to be getting worse which was verified by my last MRI. Any advice? Thanks!!

[1171]

your figures are off. 12% PD rating = $11092.50 at max rate.
http://www.pdratings.com/storage/2018PPD...Charts.pdf
which means that approx $49K of their offer is for future medical.
unfortunately there is no meaningful average settlement value you can use to judge the offer; there are too many variables.
it's very difficult to overcome a QME opinion; their whole purpose in the system is to avoid each side getting extreme medical opinions.
if it's not settled before the courts decision is issued, you'll get the PD payments and open medical coverage.
maybe your atty has some evidence to present that will challenge the QME rating.
Generally the defense will make some reasonable efforts to avoid a trial but there is a limit.

[California_Help]

(07-13-2018, 07:40 PM)1 Hurt nurse Wrote: Hi!
So my lawyer and the workers comp lawyer couldn’t agree on a settlement so we are going to trial Monday morning. My lawyer says there’s nowhere to go but up since he feels my QME rating was too low but the defense attorney is intimidating and unreasonable. I have no idea what to expect. My total rating so far for back and neck was 12% which equals about $29,000 in PPD. Defense offered $60,000 minus what I’ve received in PPD and $5000 less for overpayment of SDI but my lawyer says that not enough. What is an average payout for a lower back and neck injury for a nurse in California? Is there such a thing? Also, I live out of network now and have been unable to get insurance to send paperwork for approved therapy or a change in doctors. Since I have a lawyer now I am unable to contact my adjuster directly and their lawyer just ignores everything. I think settling is the best so I can get the help I need but don’t want to regret anything since my back seems to be getting worse which was verified by my last MRI. Any advice? Thanks!!

It can be very difficult to obtain treatment out of state due to some of the things you wrote about above. There are caps on most physical therapy, chiro etc.

Do you have alternative health insurance you can use? If so, I would recommend settling this claim with a compromise and release to get out of this system entirely. This is my non expert opinion due to what I have experienced and also seen happen to others.