[Animatedbreak84]

Hi all,


I'm am from ca and have been in a accident in work that has left me basically wheelchair bound. I have severe nerve damage in my legs. Since I am not able to walk I am not able to do much.  So basically after being on Lyrica for 8 years. The insurance company said they will no longer be paying for it because they have seen no improvement of funcatonaility. My response to the doctor well what about how the medication makes the pain go away. The doctor said the state of ca does just approve meds just cause it makes your pain better there worried about Improving your function. But due to my injury since I cannot walk no use of legs or feet is there something I can do. I have rsd and chronic pain

[California_Help]

(07-14-2016, 01:18 AM)Animatedbreak84 Wrote: Hi all,


I'm am from ca and have been in a accident in work that has left me basically wheelchair bound. I have severe nerve damage in my legs. Since I am not able to walk I am not able to do much.  So basically after being on Lyrica for 8 years. The insurance company said they will no longer be paying for it because they have seen no improvement of funcatonaility. My response to the doctor well what about how the medication makes the pain go away. The doctor said the state of ca does just approve meds just cause it makes your pain better there worried about Improving your function. But due to my injury since I cannot walk no use of legs or feet is there something I can do. I have rsd and chronic pain

I disagree with your doctor.

I am assuming you received a utilization review in the mail? You or your doctor have/had 10 days to do an internal UR appeal with the utilization review company. You and your doctor also have/has 30 days to request an independent medical review. Both of these review processes should be written in the last few pages of your utilization review. Has this time passed and were they also denied?

The rules state you have to wait 12 months before your doctor can request this medication, but there are some loop holes. If you have a substantial change of condition then he could request this again. I would think a severe increase in pain would qualify (I am not an expert). Also, if there were material fact not known during the time of the denial, for example important medical records sent to UR doctor during the time he made the denial then this may qualify for a new request. There is a box on the request for (RFA forms) that states change of material fact or condition. This is where your doctor can request it again (maybe).

I am not too familiar with Lyrica and side effects from stopping it but did they state they would decrease the dose or just deny it completely? If you are having any withdrawals or cannot tolerate pain I would suggest calling your doctor and discuss going to the emergency room. I would recommend giving the emergency room your work comp claim information and claims adjuster info to bill. If you receive a bill from this I would recommend calling the hospitals billing department and state this is an accepted work related injury and they may be subject to a fine from Ca State Department of Insurance for up to 3 times the amount of the bill, and you will contact and file a complaint with this department if they attempt to collect from you.

Do you have alternate insurance you can use in the mean time?

If the time has not past to appeal the UR denial I can try to help you with it, but it is best if your doctor appeals it. Not all doctors appeal UR denials and not all doctors know how. It sounds like from your doctors comments he is at least somewhat familiar with this horrible system.

By the way I think it is horrible that anyone would cut off your Lyrica how you describe your current medical condition. if you do not have an attorney and can call your adjuster freely, I recommend doing so and hopefully you have one with a heart and a brain who will just authorize your medication.
If you are represented by an attorney, I would not recommend contacting your claims adjuster.

What type of doctor do you have is he a pain management doctor?

[Richard+Catz]

California only, I have a lifetime medical judgement managed by Broadspire and EVRY MONTH I have to fight a denial for my pain medication refills since November 2015. I have found one resource, free to use every month I file an official complaint against Broadspire with the California Department of Industrial Relations the State oversight for Workers Comp issues in California... Here's the link; http://www.dir.ca.gov/dwc/FORMS/Utilizat...ntform.pdf I hope it does that as a link otherwise simply cut/copy it to your browser address bar. save it as you'll likely need to use it again and again.

[Animatedbreak84]

Thank you very much CALIFORNIA I hope you're not the only one who disagree with the doctor i do.  The doctor did file for that Imr  and they upheld it. They said that since they had not seen any functionality improvement there was no basis on them to allow me to receiving Lyrica.
 But again I have no use of my lower extremities whatsoever so how do they expect me to function better if I'm in a wheelchair that's just impossible . 

 Yes I am familiar that if it is upheld that you cannot receive the medication for 12 months however if your medical condition has changed that would qualify for a new requests which this is the road that I'm headed towards because my condition has worsened not having this medication

There have been several trips to the ER when I was unable to the medications and they put in for it yes and I will give them my insurance information so they can bill the work comp company

As far as the doc I had he is my PTP but he specializes in pain management

[California_Help]

(07-14-2016, 03:11 PM)Richard+Catz Wrote: California only, I have a lifetime medical judgement managed by Broadspire and EVRY MONTH I have to fight a denial for my pain medication refills since November 2015. I have found one resource, free to use every month I file an official complaint against Broadspire with the California Department of Industrial Relations the State oversight for Workers Comp issues in California... Here's the link; http://www.dir.ca.gov/dwc/FORMS/Utilizat...ntform.pdf I hope it does that as a link otherwise simply cut/copy it to your browser address bar. save it as you'll likely need to use it again and again.

It sounds like your doctor or claims adjuster may be sending in your medications every month to UR. Depending upon how they are handling claims, I would like to make a few suggestions.

If you do not have an attorney I would recommend contacting your claims adjuster and ask her if there is a way not to send these through EVERY month, especially if you have been able to successfully appeal these denials. They are spending a lot of money on UR/IMR and unless your condition has changed it makes no sense to me to have your medications reviewed EVERY month.

Some doctors offices are not sending medications to UR every month, only new things. They just send the RFA to the claims adjuster and do not put medications on it. I do not suggest this unless you discuss with your doctor. Some claims adjusters demand all medications EVERY month to be sent to UR. I have no idea what situation you are in.

When you send in the UR complaint can I ask what grounds you are complaining, for example late UR etc?

Are you or your doctor able to appeal your UR denials internally with the UR company, so you do not have to deal with IMR?

[California_Help]

(07-14-2016, 06:29 PM)Animatedbreak84 Wrote: Thank you very much CALIFORNIA I hope you're not the only one who disagree with the doctor i do.  The doctor did file for that Imr  and they upheld it. They said that since they had not seen any functionality improvement there was no basis on them to allow me to receiving Lyrica.
 But again I have no use of my lower extremities whatsoever so how do they expect me to function better if I'm in a wheelchair that's just impossible . 

 Yes I am familiar that if it is upheld that you cannot receive the medication for 12 months however if your medical condition has changed that would qualify for a new requests which this is the road that I'm headed towards because my condition has worsened not having this medication

There have been several trips to the ER when I was unable to the medications and they put in for it yes and I will give them my insurance information so they can bill the work comp company

As far as the doc I had he is my PTP but he specializes in pain management

It sounds like you have a change of condition and your doctor can now re-request the medications. It is VERY difficult to get things through IMR. In my opinion using the UR company's internal UR appeal process is so much easier to get things approved (you usually have between 5 to 10 days to appeal it through the UR company). It should state how to do this on you UR denial.

I would save copies of these hospital visits and your records from the emergency room. You can use these to appeal the next UR denial and your doctor can also use these and include them in his next request. I HOPE your pain management doctor is submitting guidelines that show your medication is warranted. The guideline used to deny is a basic one. Your condition is complex and he could submit guidelines and peer reviews on the treatment for Lyrica for RSD pain.

[1171]

you can find out more about how california work comp rules view pain management and use of pain medication by reviewing the current MTUS (title 8 of the rules & regs: 9792.24.2. Chronic Pain Medical Treatment Guidelines )
https://www.dir.ca.gov/dwc/DWCPropRegs/M...ations.pdf (page 10)
and the proposed revision of those regs
http://www.dir.ca.gov/dwc/DWCPropRegs/MT...icPain.htm

[GaylordAndNantais]

(07-14-2016, 01:18 AM)Animatedbreak84 Wrote: Hi all,


I'm am from ca and have been in a accident in work that has left me basically wheelchair bound. I have severe nerve damage in my legs. Since I am not able to walk I am not able to do much.  So basically after being on Lyrica for 8 years. The insurance company said they will no longer be paying for it because they have seen no improvement of funcatonaility. My response to the doctor well what about how the medication makes the pain go away. The doctor said the state of ca does just approve meds just cause it makes your pain better there worried about Improving your function. But due to my injury since I cannot walk no use of legs or feet is there something I can do. I have rsd and chronic pain

Your case is not uncommon. This is the sad state of affairs in today’s workers’ comp system. There are many questions: Has your case settled? Are you on Medicare? Have they offered to buy out your medical? You may be better off on your own depending how much they offer.
Getting the insurance company to provide meds that merely maintain your level of pain is difficult. Do you have a pain management doctor? What specialty is your primary doctor? The answer to these and other questions are necessary to answer before one can offer advice. However, an experienced primary treating doctor is invaluable and must be your first concern.
You need to talk to an experienced workers’ compensation attorney in order to get the advice you need. Consider your local bar association for a referral. Good luck.

[Animatedbreak84]

The state of California requires that all Rfa be summited to ur dept. so each month they send my request for meds to the ur. Which at that time they normally deny them. Being this is my guess I have over 500k   In medical bills/treatment. So to avoid more caust they just deny all treatment. My attorney automatically summits and Imr when something is denied. My question is if an Imr is upheld does that mean you have to wait a whole year or can you go to a qme?

[California_Help]

(08-10-2016, 12:48 AM)Animatedbreak84 Wrote: The state of California requires that all Rfa be summited to ur dept. so each month they send my request for meds to the ur. Which at that time they normally deny them. Being this is my guess I have over 500k   In medical bills/treatment. So to avoid more caust they just deny all treatment. My attorney automatically summits and Imr when something is denied. My question is if an Imr is upheld does that mean you have to wait a whole year or can you go to a qme?

First the law does not state the RFA must  be submitted to UR department. Your claims adjuster can approve the request and bypass the UR department. Some doctors are not automatically sending requests to UR, it depends upon how your claims adjuster has it set up. Some have all doctors send EVERY request to UR, while others do not and send directly to the adjuster. If you are not represented by an attorney you can talk to your adjuster about this, and possibly negotiate something like every 6 months or so they can be sent to UR or possibly your attorney could call your adjuster (I do not see many attorney's doing this).

You can no longer go to a QME over treatment disputes, this was replaced by IMR. If your IMR was also denied you have to wait 12 months generally unless you have a substantial change of condition, or if material facts that showed the request was warranted was not sent to UR. For example if relevant reports were not submitted in the original UR request you may be able to have your doctor request it again. There is a section on the RFA form that the doctor can check off the few reasons to request it again before the 12 month waiting period. Fraud is another reason to request a new UR, however without the IMR reviewers name I do not know how anyone can prove that.

If your attorney is just submitting the IMR application and is not reviewing your file and submitting relevant records and writing an appeal to the IMR doctor, chances are high it will be denied. In fact around 95% of all IMR's are denied. You as a patient can also submit an IMR if you have your records and want to submit them. I would recommend to discuss this with your attorney, and black out his contact info on the IMR or you will not get the notice of when to submit records. I also recommend to address all of the reasons for the original denial and submit treatment guidelines. If this is too complex for you, I would not recommend to do it. Your doctor can also help with the IMR and your appeal...the problem is most doctors will not and you have a short time window 30 days.

If you need any help with this let me know. This UR/IMR system is very confusing and time consuming.