How can I get workers comp to approve my surgery?
on 2/21/08 I fell at work, dislocated knee, torn meniscus, tissue under knee cap. It took two months for W/C to authorize a tendon release. I have two young sons so I had no choice but to use the knee best I could to care for them. Since then the knee pops out of groove two to four times a week, this has been validated by two workers comp PT’s, one W/C doctor, a EFT test and a ER doctor.
Due to the constant damage my groove is no longer straight. I have a hematoma in the patella bursa and another torn miniscus. Doc wants to secure knee cap to tibea, clean hematoma and fix miniscus, not fun but very positive in recoery.
Today W/C denied surgery due to it being medically unnecessary. All of their PT’s and Docs are in agreement, where do I go from here? I hate to hire a lawyer.
PS, I live in Florida and am just 37, I will not have my job when I return due to the work place not having lifts or elevators for three large sets of stairs in the Packing House that I would have to go up and down several times a day. Climbing stairs with my dislocation is strictly prohibited by my doctor.
Anyone have any luck chaning their adjusters minds?
Thanks for your time.
Unfortunately the knee is so swollen with the hematoma and dislocation that the knee brace and immobilizer do not fit on it. We tried taping and acing but when the knee dislocates it breaks the tape, very freaky.
When you say contact the medical office, do you mean where I am having the surgery or my private insurance?
Both of you are so quick in reassurring me, thank you. It was going to be a long sleepless night until my adjuster calls tomorrow, I’ve spent the last ten days making plans emotionally and financially for the six week recovery, now I don’t know where I stand. The adjuster didn’t even notify me I was denied, my doctor did.
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Get an attorney. In NY comp attorneys work for you at no cost. Most of the time you can’t get anywhere with the insurance companies without one.
You definitely need an attorney’s advice. If you feel you really need the surgery contact your medical insurance office and see if they will pay for it and then they can collect from the workers comp insurance at a later time. Can you wear a knee brace or use a ace bandage while working, either one will keep your knee immobile. If you can avoid it you don’t want major knee surgery, see if they will pay for anthroscopy on your knee, I had the surgery two years ago and still have some pain, but nothing like before. I had a torn miniscus, torn cartilage, and bone spurs. No fun I can relate with you on this.
~~There is no doubt about it, you must hire an attorney. Try and get referrals from people you trust. It won’t cost you any money up front as they work on contingency. It’s the only way you will get the surgery, as it has to be ordered by a judge when they they refuse medically necessary surgery. You will not only need the surgery, but a long rehab period. You have no idea of the type of disability problems/limitations you will have in the future. Work is going to be a huge issue. You never know if you will have problems walking, standing, even prolonged sitting could cause you problems. You won’t know this until you have the surgery, rehab, and are considered permanent and stationary (no further medical treatment will help). You have too much at stake here to go this alone. These attorney’s can earn their fee by making sure you get everything you need to protect yourself. Please get one right away. The W.C. is not going to help you or you would already be scheduling the surgery. Please take care and I hope all goes well for you.~~
You aren’t going to change the CA/adj mind…every thing in comp is
based on medical necessity. Just because the CA finds differently
does not mean this is true. A CA/adjuster should NOT be making
UR/Utilization Review determinations to medical necessity. Get an
atty…there is no fee for consultation, and a fee would only be
due if there is recovery, or settlement in the claim. And, fees are
awarded by judges…not necessarily agreement.
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