If you need surgery to treat your work injuries – or if you already had the surgery – it can be incredibly frustrating when the insurance carrier refuses to pay for it. Our lawyers can walk you through the process of what happens next, but there are many different ways surgery can be denied, many different facts that can affect your coverage, and many reasons to always take your case to a lawyer.
Generally, surgery coverage will be denied by the insurance company when your treating physician reports to them that you need the operation. Alternatively, the doctor may provide the care, then the insurance carrier refuses to pay for it. In either case, we have petitions we can file to have a Workers’ Comp Judge and experts review your need for surgery and potentially get the coverage granted.
For help with a Workers’ comp claim, call the Certified Pennsylvania Workers’ Compensation Lawyers at Cardamone Law today at (267) 651-7945.
Who Denied the Surgery?
Workers’ Comp is a complex system with a lot of people involved, and it can be hard to know how your surgery was denied and why.
IME Doctor
When you undergo an Independent Medical Exam (IME), a doctor hired by the insurance carrier will typically try to say that you do not need more medical care and that your treatment is over and you are at Maximum Medical Improvement (MMI) or some other type of rejection.
Treating Physician
Sometimes your care has options. Treating physicians are chosen by your employer in the first 90 days of care in most cases, and employers/insurance carriers often use doctors they know will be cheap.
It is possible you might think surgery is the best course or that another doctor recommended surgery, but your treating doctor doesn’t want to do it.
Insurance Adjuster
At the end of the day, most surgeries are denied by the insurance adjuster. When your treating physician tells the insurance company they want to do surgery, the insurance company might just say no.
However, there is no pre-approval requirement, so the doctor can provide the surgery then bill the insurance company later. This means there are two places they could say no: before or after surgery.
How to Overturn Denials
There are different courses of action you can take with help from our Bucks County, PA Workers’ Compensation lawyers to potentially get the denial overturned, though some of these methods only match with certain denials discussed above:
Claim Petition and Outside Doctors’ Reports
IMEs typically happen during the insurance carrier’s investigation of the case. You could get bad results from their IME doctor, and see the writing on the wall that they want to shut down your claim for any further medical coverage.
To get your claim granted in the first place, you may need to take your employer’s general denial and go before a Workers’ Comp Judge (WCJ) with a Claim Petition to get your benefits granted. This will require outside doctors’ reports saying that the IME doctor was wrong and that you do need ongoing care (including surgery).
Changing Doctors
If your treating physician is the one denying your care or holding up your treatment, then we may be able to switch doctors. In the first 90 days of care, you have to use doctors from your employer’s list of panel doctors, but there are some exceptions that allow you to switch doctors:
- True conflicts of interest might allow you to pick a different doctor, but the list might have backup options that have no conflicts, so you would still be stuck using doctors from the list.
- If you need a specialist that isn’t listed, we may be able to get you a surgical consult with a specialist.
- You can choose your own doctor after 90 days.
Review Petitions
Sometimes surgery is denied because it isn’t part of the treatment plan for your original injury as it was listed in your claim. A Review Petition is also filed with a WCJ (like a Claim Petition), but it seeks to review or change the terms of your original claim/determination.
If we can expand the injury/diagnosis with a Review Petition, we may be able to bring in more care options – like surgery – under the “new” diagnosis.
Utilization Review
Either side can also petition the WCJ to review the treatment. Treatment should be covered so long as it is reasonable and necessary for your recovery. The fact that it is reasonable is usually why your doctor would say you need the surgery in the first place! If the insurance carrier disagrees, we can go to court over it.
In a Utilization Review (UR), the WCJ has outside experts review the treatment and determine whether it is reasonable and necessary. There might be multiple expert opinions submitted, and it is up to the WCJ to make the final call. If they rule in your favor, the insurance carrier has to cover it.
Outside Care
Practically speaking, you can also pay for care on your own if you can afford it. You may be able to get this reimbursed if you file a separate lawsuit, but you should never spend your own money on what you can get covered through Workers’ Comp.
FAQs for Denied Surgery in Workers’ Comp
Why Might the Insurance Carrier Deny Surgery?
In reality, the reason most surgeries are denied is simple: the insurance carrier doesn’t want to pay for it. On paper, they need to give reasons, which usually involve the following:
- IME doctor says you don’t need it
- Insurance company thinks it isn’t reasonable
- Insurance company thinks it isn’t necessary
- It doesn’t match with the injury you were approved for
- The insurance company thinks you have already reached maximum medical improvement, and further care will not help you.
Does Workers’ Comp Pre-Approve Surgery?
Technically, there is no pre-approval process in Workers’ Comp. The treating physician can decide the care is necessary, administer the care, then bill insurance. In this situation, you might not find out until after the surgery is complete that insurance won’t pay for it.
In reality, the doctor is often in communication with the insurance company and may be told ahead of time that surgery will not be approved.
Can I Get a Second Opinion on Surgery?
Workers’ Comp requires you to use your employer’s chosen panel doctors in the first 90 days. If they say you need surgery, you can get a second opinion covered with a doctor of your choice.
However, this usually comes up in cases where they tell you that you need surgery but you don’t want it, not in the situation here, where they say no to surgery that you actually want/need.
Call Our Workers’ Compensation Lawyers in Pennsylvania Today
For help with your case, call Cardamone Law’s Philadelphia Workers’ Compensation lawyers at (267) 651-7945.
