Obtaining a medical treatment has changed radically for all existing workers compensation cases as of July 1, 2012 and applies to all dates of injury that have stipulated awards for future medical care or in active ongoing cases. If you have suffered a work injury and are in need of medical care, these procedures will apply to you. If you have any questions regarding obtaining medical care or navigating the workers compensation system, please contact my office via this website or by telephone. I answered the following question at AVVO.com and hope it helps you understand the current state of appealing medical denials in work comp cases.
Answer: Unfortunately for you, medical treatment in workers compensation has undergone a series of reforms beginning in 2003 which began implementing utilization review. In 2005 the insurance industry implemented medical provider networks. And as of July 1, 2012, all existing cases are now covered by independent medical review.
As of July 1, 2012, this is your new process to obtain medical treatment. Assuming transfer of care protocols are done, you have to choose an insurance selected physician within the medical provider network. Assuming you find a doctor who will see you, pretty much anything that Dr. requests on the new “request for treatment” form will be sent to utilization review which in my experience will certainly be denied nine times out of 10. Once you receive your denial, and you still want the disputed treatment, you’ll have to send it into the independent medical review system. Assuming the carrier sends all the records and complies with utilization review timelines, the answer from the independent medical review will be final. There is no judicial review at this time for independent medical review. If your treatment request is denied through independent medical review, you must wait a year before you can ask for it again.
You should find a doctor within your medical provider network who is familiar with how to do the request for treatment forms and navigate utilization review and independent medical review.I suggest you begin writing letters to your state legislator if you are unhappy with the current system as there is some momentum to change it this year.