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And The Fight Begins.... NY
#11
This has happened with 2 different surgeons and 3 different physicians in Pain Management.. IC always says Not Medically Necessary.. With the MRI (3) requests, IC says they don't approve for just pain... but from what I've read that has been sent to them, everything from my other post as been listed in the MG-2....
IC even tried to deny payment to the emergency room when my legs gave out on the cellar stairs.. but the lawyer fought that with a report from ER physician....
Like I said before.. ever since I settled the work part.. they have denied any and all procedures..
 
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#12
Well... surgeon is NOT impressed with the IC or comp.. He is going to put in for the MRI once again. Rewording everything and adding the fact that my medical records show that the last one ever done on the lower back was before the SCS. He also told me to tell my lawyer to file an appeal for a hearing.
Also waiting for a call from NY Spine and Wellness to see what else can be done and approved...

So now it's a waiting game once more...
 
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#13
I am sorry you are going through this. Interesting this happened after you settled part of your case. I know you have gone through a very difficult time trying to get testings, treatment etc. You are unfortunately not alone.

According to your states guidelines:

Your doctor needs to write how long your injury has been going on ( )years, with significant deterioration, with chronic radicular pain syndrome lasting over 6 weeks and your condition is not trading towards improvement in fact has gotten significantly worse since last MRI scan. and patient is considering prompt surgical treatment assuming MRI confirms nerve root compression. (if this is your situation). He can also quote the guidelines below.


http://www.wcb.ny.gov/content/main/hcpp/...TG2012.pdf


I copied the guideline from above below. You can read what it says and what your doctor needs to write to get it approved. He also needs to address things that are listed below that could be used to deny it, like age of injury. With utilization review they may not have access to your past medical records (I don't know the rules in your state). Send the request as if they will not know or have access to any of your medical records to get the best chance for approval. Your doctor may have already done so (just in case).


C.1.b.vii
MRI is recommended for patients with subacute or chronic radicular pain syndromes lasting at least 6 weeks, in whom the symptoms are not trending towards improvement, if both the patient and surgeon are considering prompt surgical treatment, assuming the MRI confirms ongoing nerve root compression.


C.1.b Magnetic Resonance Imaging (MRI)

MRI is considered the gold standard in diagnostic imaging for defining anatomy because it has the greatest resolution of any test currently available. While CT remains an important analytical tool especially for evaluating bony or calcified structures of the spine, due to the greater resolution of MRI, particularly with respect to soft tissue of the spine (nerve root compression, myelopathy to evaluate the spinal cord and/or differentiate/rule out masses), there is less need for using CT at the current time. Ferrous material/metallic objects in tissue is a contraindication for the performance of an MRI.

Inadequate resolution on the first scan may require a second MRI using a different technique. A subsequent diagnostic MRI may be a repeat of the same procedure when the rehabilitation physician, radiologist or surgeon documents that the study was of inadequate quality to make a diagnosis. All questions in this regard should be discussed with the MRI center and/or radiologist.

Recommendations:

page21image803505232 page21image803505552
Second Edition, January 14, 2013

14

C.1.b.i C.1.b.ii

C.1.b.iii

MRI is not recommended for acute back pain or acute radicular pain syndromes in the first 6 weeks, in the absence of red flags.

MRI is recommended for patients with acute back pain during the first 6 weeks if they have demonstrated progressive neurologic deficit, cauda equina syndrome, significant trauma with no improvement in atypical symptoms, a history of neoplasia (cancer), or atypical presentation (e.g., clinical picture suggests multiple nerve root involvement.

MRI is recommended for acute radicular pain syndromes in the first 6 weeks if the symptoms are severe and not trending towards improvement and both the patient and the physician are willing to consider prompt surgical treatment, assuming the MRI confirms ongoing nerve root compression.

 Frequency/Duration: Repeat MRI imaging without significant clinical deterioration in symptoms and/or signs is not recommended.


C.1.b.iv

C.1.b.v

C.1.b.vi

C.1.b.vii

MRI is recommended for patients with subacute or chronic radicular pain syndromes lasting at least 6 weeks, in whom the symptoms are not trending towards improvement, if both the patient and surgeon are considering prompt surgical treatment, assuming the MRI confirms ongoing nerve root compression.

In cases where an epidural glucocorticosteroid injection is being considered for temporary relief of acute or subacute radiculopathy, MRI at 3 to 4 weeks (before the epidural steroid injection) may be reasonable (see Injection Therapies, Epidural Steroid Injections).

MRI is recommended as an option for the evaluation of select chronic back pain patients in order to rule out concurrent pathology unrelated to injury. This should rarely be considered before 3 months and failure of several treatment modalities (including NSAIDs, aerobic exercise, other exercise, and considerations for manipulation, and/or acupuncture).

Standing or weight-bearing MRI is not indicated for any back or radicular pain syndrome or condition. In the absence of studies demonstrating improved patient outcomes, this technology is currently considered experimental.
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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#14
He may have already done all of this and they are ignoring what he writes and deny anyway.
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
This is the answer from my lawyer....

Ok...will do..but look at the decision...they are denying because doctor office is not putting enough reasons why this is covered under the guidelines...they have particular requirements in order to meet the threshold ...hopefully the doctor can add the proper info for it to be approved..as a backup..you can put under Medicare if comp continues to deny...thx


I mean, how much more can he put on there??
 
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#16
What I do is look at the reasons listed in the denial and then look at your doctors request. Is it missing something in the request? They should list the reason(s) for the denial.

According to the guidelines for your state for lumbar MRI it looks like a doctor needs to write how long patients injury has been going on ( )years, with significant deterioration, with chronic radicular pain syndrome lasting over 6 weeks and condition is not trading towards improvement in fact has gotten significantly worse since last MRI scan, and patient is considering prompt surgical treatment assuming MRI confirms nerve root compression (if this is your situation). He can also quote the guidelines I listed in previous post. I am assuming the UR doctor denied the request listing something I listed?
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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#17
Spine and Wellness appt... today.. shocked at how I'm being denied treatment or even procedures... So they are gonna put in a request for a EMG to my lower back and my right leg... if it all shows nerve damage, then they will also request an MRI.. records are showing last one was 2014..
Love when they tell you to close your eyes and ask if you feel this or that... left leg felt her touching... right leg nope... She is also putting me on Meloxicam 1 AM and 1 PM.. she says we need to try and get the swelling down and pain under control.. She also agreed that if this isn't taken care of the correct way, I will be in a wheelchair sooner than later..

Taking bets on how fast they get a denial from the Carrier....
 
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#18
According to the link above this is what is needed in his request. The only concern I have in these guidelines is it says there has to be an MRI or CT study that is equivocal. They won't allow you to get an MRI (catch 22). Maybe the older MRI will be sufficient? I hope. I had to google "equivocal" lol and it states open to more than one interpretation; ambiguous. So your doctor has to put this in his request ( if that is what he thinks).

If this gets denied I recommend following your attorney's advice and use Medicare and alert Medicare to place it on a conditional payment. You may have to send Medicare the denial (not sure). Crossing my fingers for you. I hope your doctor has these guidelines.

In California patients run into treatment approval problems when their doctors do not know the guidelines required for approval. It took me a while to figure out how big of a problem this is. The only way to check this is for an injured worker to ask for a copy of their doctors request, get a copy of the UR denial and cross check the denial with the doctors request and review the guidelines used to deny it.

This is what I found under your states 2013 guidelines. I HOPE they are the most recent and I apologize if they are not. I just found them via google search and not familiar with your state.



Recommendations:
Second Edition, January 14, 2013
18
C.2.a.i C.2.a.ii
EDS are not recommended for patients with acute, subacute, or chronic back pain who do not have significant leg pain or numbness.
EDS (must include needle EMG and NCS) are recommended where a CT or MRI is equivocal and there are ongoing complaints of pain, weakness, and/or numbness/parasthesias that raise questions about whether there may be a neurological compromise that may be identifiable. This means leg symptoms consistent with radiculopathy, spinal stenosis, peripheral neuropathy, etc.
Nerve conduction studies are done in addition to the needle EMG both to rule out other potential causes for the symptoms (co-morbidity or alternate diagnosis involving peripheral nerves, e.g. compression neuropathies) and to confirm radiculopathy, but the testing must include needle EMG.
EDS is recommended where there is failure of suspected radicular pain to resolve or plateau after waiting 4 to 6 weeks (to provide for sufficient time to develop EMG abnormalities as well as time for conservative treatment to resolve the problems), equivocal imaging findings, e.g. on CT or MRI studies, and suspicion by history and
C.2.a.iii
New York State Workers’ Compensation Board
New York Mid and Low Back Injury Medical Treatment Guidelines
physical examination that a neurologic condition other than radiculopathy may be present instead of or in addition to radiculopathy.
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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#19
So lets break down the first part of the guidelines above and we can take bets on what they use to deny.

If your doctor writes you have leg pain and numbness but does not use the word significant the UR doctor can write for example: Denial based upon patient does not exhibit significant pain or numbness. Do you see what I did here? UR reviewers do this stuff.

The next part of the guidelines that mention equivocal gives me a headache. Do you see all the stuff they are expecting your doctor to list and if he misses something they will use it as a reason to deny? He is going to have to write (if this is your condition) a prior CT or MRI you had on ----- is equivocal and there are ongoing complaints of pain, weakness, and/or numbness/parasthesias that raise questions about whether there may be a neurological compromise that may be identifiable. This means leg symptoms consistent with radiculopathy, spinal stenosis, peripheral neuropathy, etc. If he leaves something out then the UR doctor can use it as a means to deny.

You doctor, has to also include there is failure of suspected radicular pain to resolve or plateau after waiting 4 to 6 weeks (to provide for sufficient time to develop EMG abnormalities as well as time for conservative treatment to resolve the problems), equivocal imaging findings, e.g. on CT or MRI studies, and suspicion by history and. So for example if he fails to mention your suspected radicular pain has lasted over 6 weeks and that you have done conservative treatment etc they will use that to deny too. I have seen UR denials stating patient has not attempted conservative treatment and/or pain has not lasted 4-6 weeks on patients who have claims over 10 years old. This just because the requesting doctor did not write it in the request. Then the denial comes back patient has not had pain symptoms for at least a 6 week period.

Your doctor may also be putting everything in the guidelines in his request and they are ignoring it and listing things not true. I have seen this happen to. The only way to find out is get ahold of the request and the UR denial.

Crossing my fingers for 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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#20
This is the problem... Medicare knows about the back injury... they know it's a comp case... they have already told me flat out they will not pay for anything as long as the medical part is open.. They said I would have to close medical out with a lump sum and use that for stuff until the money is gone THEN they take over...
Believe me, I called them and asked.. I even tried with Aetna that I have through Medicare.. and they said the same thing.
 
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