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Final Notice from W/C Medication not covered
#1
Hi Everyone: Sorry for being a pest, but let me tell you, I'm sharing this with you for a Heads Up!  I received a packet from W/C with big bold letters "FINAL NOTICE"  here's the letter:
Please be aware that this letter serves as our final notice as it relates to the payment of the following medications "Norco/Tizanidine (Zanaflex) for the injured worker "ME" on 12/19 the aforementioned medications were denied via utilization review, expert reviewer report is attached for reference... There are no further options available for appeal! On 1/11/2017 our pharmacist provided a suggested weaning protocol for your review and consideration.  In addition, I have called your office on 2 different occasions regarding this issue and I have sent same number of follow up letters to your office and the Applicants Attorney in regards to this denial determination along with the date at the which the medications will no longer be covered workers compensation.  Please be aware that stating on 2/15/2017 the medication Norco/Tizanidine (Zanaflex) will no longer be paid for by workers compensation.

I saw my Doctor on 1/13/2017, we discussed the recent noticed of 12/20/2016 I sent in my DWC IMR for review, I even faxed it to my my adjustor.  I spoke to the adjustor this afternoon and she was shocked I got a "final notice"  "you're the first client I know who has ever received a final notice" she suggested I contact my doctor and find out what medication he will recommend.  This is because of the new California Work Comp Opioid Analgesic Treatment Guidelines Aug 2016.
What the heck am I suppose to do? Start the weaning process of a medication which could cause a palpitations/heart attack during the "weaning/withdrawal process" This is terrible... So much for lifetime medical without any problems... well that's what my attorney told me during the Settlement Conference and signing!
Babebahn..."Tongues don't have erasers"
Injured 1999 3 level anterior cervical fusion 2001
Settled Work Comp Case 2006 w/ Lifetime Medical Currently, C7-T1 is being watched will possibly need surgery front/back fusion from C3-T2, lower back needs another facet injection.
 
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#2
treatment denied by work comp is often available thru your general health insurance.
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
(01-23-2017, 08:33 PM)1171 Wrote: treatment denied by work comp is often available thru your general health insurance.

My private insurance isn't going to pay for it because its a work comp issue according to my PCP
Babebahn..."Tongues don't have erasers"
Injured 1999 3 level anterior cervical fusion 2001
Settled Work Comp Case 2006 w/ Lifetime Medical Currently, C7-T1 is being watched will possibly need surgery front/back fusion from C3-T2, lower back needs another facet injection.
 
Reply
#4
(01-23-2017, 08:41 PM)Babebahn Wrote:
(01-23-2017, 08:33 PM)1171 Wrote: treatment denied by work comp is often available thru your general health insurance.

My private insurance isn't going to pay for it because its a work comp issue according to my PCP

Your private insurance will pay for it as this happened to me. You have to tell them, "Commissioner _______ ordered this." (I went to a hearing for something else and brought it up. I  told the WC commissioner to put it in writing and he did)
If you go on Avvo, you can ask attorneys anything for free. Most of them told me it "was arguable", since they are liable, by law at least in CT. 

I never received any letter. I was literally at the pharmacy waiting to pick up my oxycodone. The pharmacist came around the counter, (in order to not humiliate me in front of others) and told me, "WC just faxed a letter saying they are NOT paying for any prescriptions from Dr _____." 
I was really pissed off because they are required to notify you of any reduction, or end of any benefit with a form and the law citing the reason why this action is being taken.
Right then I had to put it on my private insurance and it went right through.

My primary care doctor was not happy at all. He also knew just cutting me off would be detrimental to my life. I told him and showed him the "hearing notes", that were mailed to me a couple days after the hearing.
If I get a 90 day supply, I pay zero co-pay. 
The part I do not agree with is them being allowed to throw a work related injury medication, at a doctor that had no part in it. 
I could have pushed for a pre-formal hearing, but since I pay nothing and have no counsel, it was not a battle I chose to pursue.

WC initially paid after a surgery, but eventually, they were going to force me to use mail order, which is not only unreliable (as far as getting it to you before you are out) but also, they are requiring the doctor to break the law by faxing a narcotic to them, so their cheap-skate-generic-meds, can be mailed to your house. 
Narcotics HAVE to be picked up in person and everyone should know that, No faxing, no mailing it. Its illegal. Any doctor who does this is putting his behind on the line, big time. 

You can fight this if you want, but I think over time, as long as your primary doctor is "ok" with dong this, and you are paying less then $6.00, it will be less annoying. The pharmacy will be happier too. They see WC and they know, its extra scrutiny, phone calls, and waiting for them to get back to the pharmacist. I had a WC pharmacy card, and it still did not make it easier.

The other upside, is, WC will have no idea what medication(s) you are taking or for how long. 
In CT. there is a new "protocol" document (online) that shows what actions they take IF you are taking a narcotic, for what body part, how long you have been taking it, and then they creep in, and snatch the meds out, without notice. 
I prefer to have the least amount of  involvement with them at this point. They try to frustrate the hell out of you, so you give up.
Good luck to you no matter which route you decide to take.
[color=#181818][size=small][font=Merriweather, Georgia, serif]The greatness of a man is not in how much wealth he acquires, but in his integrity and his ability to affect those around him positively~[/font][/size][/color]
 
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#5
You have nothing to lose by asking the insurer rather the a doc.
Your final written denial from comp as to what is covered should be more persuasive then a doctors opinion.
The regulations and ur docs have authority to decide coverage issues over a ptp.
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
(01-23-2017, 08:41 PM)Babebahn Wrote:
(01-23-2017, 08:33 PM)1171 Wrote: treatment denied by work comp is often available thru your general health insurance.

My private insurance isn't going to pay for it because its a work comp issue according to my PCP

Ask your PTP for a prescription and then take it to your pharmacy and tell them to bill your private insurance. If you get a denial from your private insurance, you will be the first on this site I have seen.

I assume you have not received the IMR determination yet? You may still get this over turned by IMR, but to do that you or your doctor should have sent relevant medical treatment guidelines and records that show the request is warranted. Often times patients conditions do not fall under the guidelines they listed. Review the UR denial completely and look for inaccuracies or if your condition does not fall under the BS or umm guidelines they used. Have you discussed with your doctor and did he help with your IMR?

If you receive or received a IMR denial make sure you review that and the UR denials. Often times relevant records were not sent and that can be grounds for your doctor to make the request again and/or if you have a substantial change in condition this may also be ground to make a request again, before the 12 month waiting period.

If you go into withdrawals go to the emergency room and give them your work comp claims info to bill Do not put yourself in that situation. Ask your doctor what to do, but in my opinion you should be able to use your private insurance once denied by work comp. If in doubt call your private insurance and ask.
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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#7
(01-24-2017, 06:56 PM)California_Help Wrote:
(01-23-2017, 08:41 PM)Babebahn Wrote:
(01-23-2017, 08:33 PM)1171 Wrote: treatment denied by work comp is often available thru your general health insurance.

My private insurance isn't going to pay for it because its a work comp issue according to my PCP

Ask your PTP for a prescription and then take it to your pharmacy and tell them to bill your private insurance. If you get a denial from your private insurance, you will be the first on this site I have seen.



I assume you have not received the IMR determination yet? You may still get this over turned by IMR, but to do that you or your doctor should have sent relevant medical treatment guidelines and records that show the request is warranted. Often times patients conditions do not fall under the guidelines they listed. Review the UR denial completely and look for inaccuracies or if your condition does not fall under the BS or umm guidelines they used. Have you discussed with your doctor and did he help with your IMR?

If you receive or received a IMR denial make sure you review that and the UR denials. Often times relevant records were not sent and that can be grounds for your doctor to make the request again and/or if you have a substantial change in condition this may also be ground to make a request again, before the 12 month waiting period.

If you go into withdrawals go to the emergency room and give them your work comp claims info to bill Do not put yourself in that situation. Ask your doctor what to do, but in my opinion you should be able to use your private insurance once denied by work comp. If in doubt call your private insurance and ask.
My adjuster said that since Peer Review states "there's no further review to appeal" it's basically closed issue... it doesn't look like they will overturn the situation. I'm schedule to see the physician again to figure out what next, I've started the weaning process and have developed palpitations but so far I'm ok.  This is a nightmare...I was ignorant in believing my Attorney when he said he would be there anytime, that lifetime medical meant I would never have trouble with medical treatment or payment.  So I think next week I will take a trip to WCAB and see if I can get some advise from someone.  Thanks for your advise.
Babebahn..."Tongues don't have erasers"
Injured 1999 3 level anterior cervical fusion 2001
Settled Work Comp Case 2006 w/ Lifetime Medical Currently, C7-T1 is being watched will possibly need surgery front/back fusion from C3-T2, lower back needs another facet injection.
 
Reply
#8
If your health insurer balks at coverage of denied comp treatment, you can contact the state for help:
http://www.ca.gov/Agencies/Managed-Healt...artment-of
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.
 
Reply
#9
(01-25-2017, 02:53 AM)Babebahn Wrote:
(01-24-2017, 06:56 PM)California_Help Wrote:
(01-23-2017, 08:41 PM)Babebahn Wrote:
(01-23-2017, 08:33 PM)1171 Wrote: treatment denied by work comp is often available thru your general health insurance.

My private insurance isn't going to pay for it because its a work comp issue according to my PCP

Ask your PTP for a prescription and then take it to your pharmacy and tell them to bill your private insurance. If you get a denial from your private insurance, you will be the first on this site I have seen.



I assume you have not received the IMR determination yet? You may still get this over turned by IMR, but to do that you or your doctor should have sent relevant medical treatment guidelines and records that show the request is warranted. Often times patients conditions do not fall under the guidelines they listed. Review the UR denial completely and look for inaccuracies or if your condition does not fall under the BS or umm guidelines they used. Have you discussed with your doctor and did he help with your IMR?

If you receive or received a IMR denial make sure you review that and the UR denials. Often times relevant records were not sent and that can be grounds for your doctor to make the request again and/or if you have a substantial change in condition this may also be ground to make a request again, before the 12 month waiting period.

If you go into withdrawals go to the emergency room and give them your work comp claims info to bill Do not put yourself in that situation. Ask your doctor what to do, but in my opinion you should be able to use your private insurance once denied by work comp. If in doubt call your private insurance and ask.
My adjuster said that since Peer Review states "there's no further review to appeal" it's basically closed issue... it doesn't look like they will overturn the situation. I'm schedule to see the physician again to figure out what next, I've started the weaning process and have developed palpitations but so far I'm ok.  This is a nightmare...I was ignorant in believing my Attorney when he said he would be there anytime, that lifetime medical meant I would never have trouble with medical treatment or payment.  So I think next week I will take a trip to WCAB and see if I can get some advise from someone.  Thanks for your advise.

I have been doing my own UR appeals and have helped others, including doctors and attorney's on how to appeal UR denials. There are loop holes, I assure you, and your adjuster is not going to tell you and may not be aware of them. If your condition greatly changes and you have increase in pain try to get into your PTP. Change of condition is grounds to make a new UR request before the 12 month waiting period. You can believe me, or believe your adjuster, but please at least ask your doctor and call and I&A officer. If you do get heart palpitations please call your doctor and have him paged and if necessary go to the emergency room and provide them with your work comp info such as claims adjusters contact info to bill. Going through withdrawals can be dangerous. Your doctor should be guiding you on this.

Again, you should also be able to send the prescription through your private insurance as other injured workers have done when in your situation, just check with your private insurance. Your doctor does not know your private insurance policy. I have yet to see one deny a CA injured worker after being denied by work comp after Affordable Care Act was passed.

Sometimes getting off a medication is a good thing, but only done safely under a doctors guidance.
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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