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Dealing with denial of medication in ca
#11
The adjuster sends all Rfa to the ur department in hopes that they will get denied. In the beginning of my injury mainly the first 3yrs all Rfa were getting approved. Since it has been 8yrs since my injury they insurance no longer wants to pay for anything since they have paid so much. 

Let's say I'm asking for a back support. When the reviewer at the ur department is viewing records from Doctor reports from 
Doctor a
Doctor b
In the reports from a and b there is no supporting evidence to why I am in need of the back support. So it's denied however the insurance company did not summit Doctor c report that states that a mri was performed and the IW has 3 budged disc. With Doctor c records it could have got the item approved. What do you do then.

Also if you have a arm issue and the Doctor puts in for thearpy and the IC denies the body part then can you got to a qme?
 
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#12
Can you appeal the findings of a Imr
 
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#13
Yes an IMR can be appealed.
Information is in the FAQs
http://www.dir.ca.gov/dwc/IMR/IMR_FAQs.htm
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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#14
(08-11-2016, 03:01 AM)Animatedbreak84 Wrote: Can you appeal the findings of a Imr

You can only appeal an IMR under a few circumstances. If relevant records were not sent, this may be a way to request a new UR, so you are not actually appealing the IMR, but starting all over. There is a short list of things you can appeal an IMR, fraud is one. To request a UR again your doctor has to mark the box change of condition or material facts. Material facts could be the missing report if it is relevant.

Why didn't you or your attorney send the record. When your attorney send in the IMR, a few weeks later he gets a paper that states he can send records to MAXIMUS. If he is just filling out your IMR application and not sending anything...it may benefit you to send in the IMR request, but you have to black out your attorney's name and contact info or they will receive the form when to send records. It is not only records that gets these overturned, you really need to read the UR denial and address anything it gives as a reason to deny, and also submit treatment guidelines yo get the best chance to get IMR's approved.

Your claims adjuster is only obligated to send the last 6 months or relevant records.

IMR's can be appealed only under certain circumstances but UR denials can be appealed every time. You do this with an internal IR appeal. The info on this is on the last few pages of your UR denial. I find it mush easier to get a UR appealed than deal with IMT. IR doctors have to provide their names and why I think they are more apt to be honest and more apt to actually read the records sent (not always). You appeal a UR denial same as IMT, send relevant records and cover letter addressing reason for denial and medical treatment guidelines. Doctors should be doing this every time but there is a 10 day window to appeal.

Another option after a UR denial is to ask your doctor to do a peer to peer phone call with the UR doctor. This sometimes works.
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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#15
Ok thank you all for your advice.

Let's say I'm a taking medication and when the doctor summits a new Rfa. For meds and its denied by the ur. The next month since I have been without medication and my pain has increased. The doctor appeals the ur decision the reason why is it was non certified 00/00/2016 let's say the reason why it was denied is because the medication was used for patients with cprs. The review did not have a file stating that I had this diagnosis, i.e. The lawyer/ ic did not summit this. However if I have a report that I have cprs as a diagnosis could I then qualify and do a re-summit of material facts. Summiting the report, with these files and the Rfa should it be summited to the ur dept
 
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#16
it may depend on how long it's been before you provided the additional information:

"(3) (A) If the information reasonably necessary to make a determination under subdivision
(f)(1)(A) that is requested by the reviewer or non-physician reviewer is not received within fourteen (14) days from receipt of the completed request for
authorization for prospective or concurrent review, or within thirty (30) days of the request for retrospective review, the reviewer shall deny the request
with the stated condition that the request will be reconsidered upon receipt of the information. "


http://www.dir.ca.gov/DWC/DWCPropRegs/IM...ations.pdf

they don't have to approve based on any doctor's say so. it may also depend on whether the doctor is authorized and whether the report/findings are credible. they could request a consultation or further testing to substantiate such a diagnosis.
doctors that fail to substantiate for UR do a great disservice to their patients.
if the liability for the condition/injury is in dispute, you will not be given an IMR determination.
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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#17
thanks everyone
1171 the file is over 60 pages, do you know where the specif section is
 
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#18
hi all,

has anyone ever filed a complaint against the ur dept? for instance if the ur dept said you were not able to receive the medication because you did not fall within the guidelines mtus chronic pain. reason for denying you did not have nerve damage etc? however you are able to provide that you do have nerve damage stated from a physician. what would happen next?
 
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#19
http://www.dir.ca.gov/dwc/DWC_FilingAComplaint.htm
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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#20
(08-24-2016, 09:02 PM)Animatedbreak84 Wrote: hi all,

has anyone ever filed a complaint against the ur dept? for instance if the ur dept said you were not able to receive the medication because you did not fall within the guidelines mtus chronic pain. reason for denying you did not have nerve damage etc? however you are able to provide that you do have nerve damage stated from a physician. what would happen next?

You can file a UR complaint but in my opinion the medical unit is a toothless tiger. I have filed many, many complaints and have assisted patients in filing complaints. I have not seen very much if anything happen. I do not see anything here that warrants a complaint, unless the UR doctor listed records in his denial and those records contained information that stated you had nerve damage. If this happened you can send a UR complaint and you can send a complaint to the CA State Medical board (if the doctor is licenced in CA).

Has it been 10 days since you received this UR denial? You or your doctor can do an internal appeal with the UR company. Many doctors do not know they can do this and it is unfortunate because it is SO much easier to appeal with a UR company than to deal with IMR, with a doctor who you do not know their name and they may not even read the records provided. The directions on how to do an internal UR appeal is located on the last few pages of the UR denial and this is separate from requesting an IMR. This is where you or your doctor can send the records that show your medication is warranted. This is also where you can send treatment guidelines to show your medication is warranted. You will get a different UR doctor when you do this internal appeal. If you need help with this let me know.

I would also recommend requesting an IMR. If you have an attorney I would not rely on them to do IMR appeals correctly unless you know for sure they are actively sending records to MAXIMUS. 

Did the UR doctor receive any records from the requesting doctor that you have nerve damage (not clear with your post)? If not your doctor should be able to request this again and mar the RFA box that states change of material facts (something like this do not recall). It means UR did not receive records that showed the request was warranted. I would discuss this with your doctor.

If your condition falls outside of MTUS chronic pain guidelines you may be able to use other guidelines.
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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