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Dealing with denial of medication in ca
#21
I've kind of been debating whether or not to do a complaint against the Imr department. I just thought by filing a complaint it would at least start the process for the complaint department to look into the doctor completing the review. The reason for the complaint would be how my PTP Dr. notated in his records that I do have RSD which is associated with nerve damage. Yet however The reviewer just put in the stuff from the MTUS guidelines that state this medication is used for patients who have nerve damage. Which appeared that when the doctor denied the request for treatment he overlooked information that justified my reason to be allowed to have the medication. This would be my bases for filing a formal complaint I am for Fimiliar that you can appeal the decision internally with the UR company but I heard when the PTP does this that the reviewer is not obligated to make a response. This information was given to me by my lawyer.
 
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#22
(08-28-2016, 10:11 PM)Animatedbreak84 Wrote: I've kind of been debating whether or not to do a complaint against the Imr department. I just thought  by filing a complaint it would at least start the process for the complaint department to look into the doctor completing the review.
I agree (but do you mean a complaint against UR or IMR compaint?).If it is against UR I just want to make sure the UR doctor had the records that stated you have nerve damage. Often times they only receive a few reports, and  why there is a UR internal appeal process. The UR denial should list the records that were included in his review. If those records stated nerve damage, then I would file a UR complaint.

Also, I recommend you google the UR doctor and check to see if he is a correct specialty to deny this medication.


The reason for the complaint would be how my PTP Dr. notated in his records that I do have RSD which is associated with nerve damage. Yet however The reviewer just put in the stuff from the MTUS guidelines that state this medication is used for patients who have nerve damage. Which appeared that when the doctor denied the request for treatment he overlooked information that justified my reason to be allowed to have the medication. This would be my bases for filing a formal complaint
Again, as I wrote above I would check the reports listed in the UR denial as these UR doctors do not get your entire file and sometimes only get the RFA.

I am for Fimiliar that you can appeal the decision internally with the UR company but I heard when the PTP does this that the reviewer is not obligated to make a response. This information was given to me by my lawyer.

The UR company does not have to have a internal UR appeal process I agree....but MOST of them do. If your UR company has an internal UR appeal process, I believe they are obligated to respond. I will look into this though to make sure. 

I have been helping injured workers in California for a number of years and disagree with what your attorney stated to you. In my opinion doing internal UR appeals is the best chance to get these denials approved. IMR has a 95% denial rate. I have tried to appeal through IMR and I have found many of the IMR doctors just ignore the records sent. At least with UR you get their name and they appear more accountable. Also, when you or your doctor does an internal UR appeal the UR company will use a different doctor. You or your doctor can write an appeal letter that points out in your records that you have RSD and you can include missing records. You can also include treatment guidelines if your condition falls outside of MTUS chronic pain.

In my opinion many attorney's and doctors are not aware of how internal UR appeals work. I have been doing these internal UR appeals even before the IMR process went into effect in 2013. UR company's are not obligated to have an internal UR appeals process.

The thing about doing an internal UR appeal is that it does not mean you cannot still request an IMR. You can do both at the same time and cancel the IMR if it gets approved. It is another chance for you to get something approved and in my opinion a better chance than the 95% denial rate IMR has. 

I am sorry about your RSD. If you need more help with doing these appeals I am here to help you. 


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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#23
This is for your question about can you appeal an IMR.

https://www.workcompcentral.com/columns/...257c097a1e



Also, above you asked doctor a requests a back brace and UR only receives reports from doctor b and nothing that shows the request is warranted, what do you do then? You or your doctor has 10 days from the original UR denial to send those records and request an internal UR appeal. Ir your doctor can send the relevant records when he is making his request.
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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#24
(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?

I recently had a denial in C. I was switching Pain Medications, at the same time my insurance carrier was switching my account service to a new carrier. long story short they didn't inform me or my Dr of a carrier change so the new carrier didn't get the update. Took me a week to contact my Insurance to hear about the new carrier. Another week of calls an fax 's to reach a carrier rep by this time I was five days out of pills.. Was told I'd have to wait. I finally told them they had to end of business Friday-- the next business day or I would simply pay myself and $700 and file it in Small Claims Court.. THAT GOT RESULTS I had the pills that afternoon.

Hope you don't need to do this but it worked for me.
Sad  CDC Guideline 2016 Prescribing Opioids for Chronic Pain will be the death of me.
[url=http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm]http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm[/url]
 
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#25
claims don't transfer between carriers; the one that got the premium keeps the claim.
maybe you have a self-insured employer that changed administrators?
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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#26
(10-13-2016, 03:02 PM)Richard+Catz Wrote:
(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?

I recently had a denial in C. I was switching Pain Medications, at the same time my insurance carrier was switching my account service to a new carrier. long story short they didn't inform me or my Dr of a carrier change so the new carrier didn't get the update. Took me a week to contact my Insurance to hear about the new carrier. Another week of calls an fax 's to reach a carrier rep by this time I was five days out of pills.. Was told I'd have to wait. I finally told them they had to end of business Friday-- the next business day or I would simply pay myself and $700 and file it in Small Claims Court.. THAT GOT RESULTS I had the pills that afternoon.

Hope you don't need to do this but it worked for me.

Or tell them if you go through withdrawals you will go to the emergency room and hold the claims adjuster themself civilly liable for any damages they have caused... you may also get a response.
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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#27
(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?

Get them the statement provided by the physician. If you are being on the wheelchair for a long time and unable to do work definitely you need to get compensation. I think that this may help you ****Moderator edit - No advertising in this forum. Giving you the benefit of the doubt that it was not intentional**** You have to be compensated for your pain and sufferings too. If you think that your physician is not providing you enough treatment, you can file a case against the physician too.
 
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#28
comp does not provide benefits for pain and suffering.
you will Need evidence of malpractice in order to proceed with a malpractice case against a physician.
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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