Hello my friends!
Today I received the dreaded denial letter and was beyond surprised to find it riddled with incorrect information.
Here is a brief hx before getting into the problems with the denial: I am 37 years old and was injured Nov/11 at work while restraining a psychiatric patient. I sustained a bilateral pars fx at L4/L5 with Spondylolysis and Spondylolisthesis as well as a small bulge (1-2mm), some foraminal narrowing was noted. I also have had moderate to severe radiculopathy. Flexion xrays show progression of injury from a Stage 1 to Stage 2 and visible fx of the Pars the obvious cause of my severe instability. I've had 5 weeks of PT, 2 LESI (3rd was denied). I have difficulty standing and getting up from sitting. I also walk with a limp most days. I continue to have pain down my right leg and pins/needles in my right foot. My Dr. attempted to send me back to work but after 4 days my pain was to severe so I am now again totally off work receiving WC benefits. At this point I am at MOST 50% - 60% better and that is being generous.
Ok, so today I got the letter from a group called FORTE, it's an independent clinical review for the private insurance carrier. They said in the report that "IW is a 44 year old female who was assaulted by a co-worker at work. MRI showed a grade 1 spondy l4/l5 with "possible bilateral mild bilateral foraminal stenosis" They then go on to say that I am now 60-70% better. Then the letter says that the request for fusion is denied because I haven't met their parameters for surgery.
I am totally at a loss right now because the WC insurance agency said the claim would not be denied based on the info they had received that a fusion at this point is needed. I am beyond irritated that they got my age wrong and left out all my test results and missed important information from my MRI.
This is all new to me. Fortunately my claim has been handled quite well up to this point. I have a workers comp rep from work who steps up and gets things done with little effort on my part. I plan on calling her Monday to inform her of their mistakes in their report.
I don't know what my rights are other than filing with the state of CA for an appeal. Do independent clinical review agencies make such blatant mistakes? I am just beside myself at the thought of prolonging this much longer.
If anyone knows what my options are or has some words of wisdom, a little advice, i'd greatly appreciate it. I am in pain and frustrated. I honestly don't know how to handle this speed bump.
Your help is greatly appreciated