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California - Lifetime Med - Coverage Terminated
#1
Where to start - California Workman's Comp- settled with lifetime medical in 2000. They initially covered my pain management procedures - then after a few years, it became a nightmare to get covered. They have been covering my medications until this month. Without notice, they stopped covering the opiods that I have been taking for 15 years.


Can they do this without any notice? I am not working and in the process of going on SSDI, due to the issues I am having with my health, related to this injury. I do not know where to tuen on this. I do not live in California anymore, so I do not know where to turn.


Thanks for any advice that can be provided
 
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#2
There are many reasons why your medications were not filled. You stated without notice they stopped them. Did you receive a utilization review denial for the medications and if so did you or your doctor appeal it through the utilization review appeal process and the IMR process?
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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#3
Sorry I cannot edit my post. I meant to write there are many reasons why medication is not refilled in the California work comp system.

1. Pharmacy did not get a response or approval from the claims adjuster as it was still being reviewed and pharmacy took this as a denial. Asking the pharmacist to run the request again usually resolves this.
2.Doctor did not send in the request on a RFA form.
3. Doctors office never sent in the request for refill.
4.Request was denied by UR and doctor did not appeal it through the internal UR process or through the IMR process.
5. Medications were denied due to medications previously being denied within a 12 month period without a change of condition or material facts known.
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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#4
I would need to know why you did not receive your refill before I can recommend how to move forward.

If you did not receive a utilization review denial in the mail and have no idea why you did not receive a refill then you will need to contact the pharmacy and ask them to run it again would be my recommendation. If they did and still denied I would ask for the print out of the denial from the pharmacy and then contact your doctors office and investigate what happened there. Do they have a fax or mail confirmation it was sent to the adjuster or UR company and was the request sent on a RFA form?

If you received a utilization review denial in the mail that is going to be a longer response. Your doctor has a short amount of time to do an internal UR appeal and you have 30 days to request an IMR. The info about this should have been included in the UR denial.

If you are not represented you can also contact your adjuster about the refill.
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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#5
(01-23-2019, 10:55 AM)spine pain Wrote: Where to start - California Workman's Comp- settled with lifetime medical in 2000. They initially covered my pain management procedures - then after a few years, it became a nightmare to get covered. They have been covering my medications until this month. Without notice, they stopped covering the opiods that I have been taking for 15 years.


Can they do this without any notice? I am not working and in the process of going on SSDI, due to the issues I am having with my health, related to this injury. I do not know where to tuen on this. I do not live in California anymore, so I do not know where to turn.


Thanks for any advice that can be provided

Treatment approvals and the documentations are handled between the physician & the carrier, generally the patient is not part of that correspondence. I suspect a recent update to the drug formulary was not adequately addressed by your treating physician.
The formularies are here
https://www.dir.ca.gov/dwc/MTUS/MTUS-For...rders.html
You should contact your doctor about getting preapprovals from the carrier for
The highly controlled long time use of opioids. The treatment guidelines do allow for a surpervised plan to reduce patient dependencies on opioids.
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
(01-23-2019, 01:36 PM)1171 Wrote:
(01-23-2019, 10:55 AM)spine pain Wrote: Where to start - California Workman's Comp- settled with lifetime medical in 2000. They initially covered my pain management procedures - then after a few years, it became a nightmare to get covered. They have been covering my medications until this month. Without notice, they stopped covering the opiods that I have been taking for 15 years.


Can they do this without any notice? I am not working and in the process of going on SSDI, due to the issues I am having with my health, related to this injury. I do not know where to tuen on this. I do not live in California anymore, so I do not know where to turn.


Thanks for any advice that can be provided

Treatment approvals and the documentations are handled between the physician & the carrier, generally the patient is not part of that correspondence. I suspect a recent update to the drug formulary was not adequately addressed by your treating physician.
The formularies are here
https://www.dir.ca.gov/dwc/MTUS/MTUS-For...rders.html
You should contact your doctor about getting preapprovals from the carrier for
The highly controlled long time use of opioids. The treatment guidelines do allow for a surpervised plan to reduce patient dependencies on opioids.

Sorry for the delay in communications, It's been a very trying time for me lately. The adjustor approved last month, now she wants to RFA sent in for the medications. I am out of state, my pain management doctor's office doesnt want to fill out the form. Recently,I was informed that my file - case was taken over by a new law firm on behalf of California's guarantee fund. I have not had to submit one of these RFAs ever for medication (I have been out of state for years) Like everyone else, they use to cover procedures to help with pain, but they always find a reason to deny in the IMR. My pain doctor is highly ranked and is associated with some of the groups that are referenced in the WCAB Chronic pain guideline.

I am going to work with him to submit a RFA for the meds, but based on my experience, they will deny. My understanding is that you need to show functional improvement. Recently, I have taken a turn for the worse, so I am concerned that this will be used against me. My docs are pushing for a spinal cord stim again, which I have been apprehensive to try again.

My understanding is that if you do not use these lifetime benefits within a set period of time, they automatically will cancel them. Does anyone know where I can verify that? I have applied for SSDI and in that loop now, so that will take a bit of time and fingers crossed, positive on the other side. I have been battling this for years, the docs have told me I should go out. The pain meds have been a big part of enabling that functionality.

Thanks for your help and responses
 
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#7
(01-23-2019, 01:36 PM)1171 Wrote:
(01-23-2019, 10:55 AM)spine pain Wrote: Where to start - California Workman's Comp- settled with lifetime medical in 2000. They initially covered my pain management procedures - then after a few years, it became a nightmare to get covered. They have been covering my medications until this month. Without notice, they stopped covering the opiods that I have been taking for 15 years.


Can they do this without any notice? I am not working and in the process of going on SSDI, due to the issues I am having with my health, related to this injury. I do not know where to tuen on this. I do not live in California anymore, so I do not know where to turn.


Thanks for any advice that can be provided

Treatment approvals and the documentations are handled between the physician & the carrier, generally the patient is not part of that correspondence. I suspect a recent update to the drug formulary was not adequately addressed by your treating physician.
The formularies are here
https://www.dir.ca.gov/dwc/MTUS/MTUS-For...rders.html
You should contact your doctor about getting preapprovals from the carrier for
The highly controlled long time use of opioids. The treatment guidelines do allow for a surpervised plan to reduce patient dependencies on opioids.

I think this is the issue - both of meds are non exempt. Like I mentioned in the other thread, UA has been an absolute nightmare. I called the adjuster and they mentioned that they would gladly settle the lifetime, if I would like. Timing is just really bad.
I have been compliant on the use of the meds and I have even reduced down to the CDC guidelines. My injury is one that I will have pain the rest of my life.
 
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#8
(02-18-2019, 01:52 PM)spine pain Wrote: [quote='1171' pid='168772' dateline='1548264995']
[quote='spine pain' pid='168768' dateline='1548255319']




My understanding is that if you do not use these lifetime benefits within a set period of time, they automatically will cancel them. Does anyone know where I can verify that? I have applied for SSDI and in that loop now, so that will take a bit of time and fingers crossed, positive on the other side. I have been battling this for years, the docs have told me I should go out. The pain meds have been a big part of enabling that functionality.

Thanks for your help and responses
Your understanding is incorrect. Your court award for future medical treatment is lifetime limited. Refer to your original award documents.
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
(02-18-2019, 02:28 PM)1171 Wrote:
(02-18-2019, 01:52 PM)spine pain Wrote: [quote='1171' pid='168772' dateline='1548264995']
[quote='spine pain' pid='168768' dateline='1548255319']




My understanding is that if you do not use these lifetime benefits within a set period of time, they automatically will cancel them. Does anyone know where I can verify that? I have applied for SSDI and in that loop now, so that will take a bit of time and fingers crossed, positive on the other side. I have been battling this for years, the docs have told me I should go out. The pain meds have been a big part of enabling that functionality.

Thanks for your help and responses
Your understanding is incorrect. Your court award for future medical treatment is lifetime limited. Refer to your original award documents.

Thanks.. I heard this a while back. I do have the court stipulation for "Lifetime" medical. There is a special place in hell for these guys. If they continued to approved any of the modalities, other than opiods, it would be helpful for the injured worker. They use to cover procedures like clock work, now it has been a total fight and you cannot win. Add to that, the last bit, that enabled functionality, pain meds. I am also reading that spinal cord stimulators are not in favor for workmans comp. I was interested in trying them again, I have had a trial a few years ago, but I didnt go for the implant. The new high frequency ones are supposedly firly decent. Tired of fighting a battle with these guys so I can live somewhat of a life. Anything to screw the injured worker.


Thanks for your help
 
Reply
#10
(02-18-2019, 02:28 PM)1171 Wrote:
(02-18-2019, 01:52 PM)spine pain Wrote: [quote='1171' pid='168772' dateline='1548264995']
[quote='spine pain' pid='168768' dateline='1548255319']




My understanding is that if you do not use these lifetime benefits within a set period of time, they automatically will cancel them. Does anyone know where I can verify that? I have applied for SSDI and in that loop now, so that will take a bit of time and fingers crossed, positive on the other side. I have been battling this for years, the docs have told me I should go out. The pain meds have been a big part of enabling that functionality.

Thanks for your help and responses
Your understanding is incorrect. Your court award for future medical treatment is lifetime limited. Refer to your original award documents.

Thanks.. I heard this a while back. I do have the court stipulation for "Lifetime" medical. There is a special place in hell for these guys. If they continued to approved any of the modalities, other than opiods, it would be helpful for the injured worker. They use to cover procedures like clock work, now it has been a total fight and you cannot win. Add to that, the last bit, that enabled functionality, pain meds. I am also reading that spinal cord stimulators are not in favor for workmans comp. I was interested in trying them again, I have had a trial a few years ago, but I didnt go for the implant. The new high frequency ones are supposedly firly decent. Tired of fighting a battle with these guys so I can live somewhat of a life. Anything to screw the injured worker.


Thanks for your help
 
Reply
  


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