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Workers Comp Are they going to deny my spinal fusion!?

So here is a quick synopsis of what’s been going on with me. I am 29 years old my job is at times physically demanding. In 2014I had a laminectomy discectomy The surgery was successful and I return to work with absolutely no limitations two months after surgery I have not been treated by a doctor for my back since. Prior to my surgery I had tried 10 rounds of steroid epidural, I had my nerves burned to help ease my pain and did 15 months of physical therapy. None of that helped me.

I was injured over a month ago during a training course for  my job. It was literally just a freak accident that was no one’s fault. I was immediately approved for Worker’s Comp. as they couldn’t tell me that I wasn’t injured at work. I have been receiving treatment although not the best. They sent me to occupational health instead of the orthopedic that I was recommended to see when I was seen in the emergency room after the accident. Since Worker’s Comp. was not treating me for my back injury but was treating me for the slew of other injuries that I had   Sustained I was able to see my surgeon from a prior back surgery on my private insurance at the direction of my attorney. Once my attorney served Worker’s Comp. and my Case Worker to let them know that I have legal representation they magically sent me to an orthopedic. My doctor at that point had already recommended a spinal fusion. I had my surgery scheduled and all my presurgical screening and testing was completed. However since technically I was injured at work as soon as Worker’s Comp. sent me to an orthopedic my private insurance would no longer cover me for   For my surgery. So I had to postpone it, I was seen by two workers comp orthopedic doctors the first one said that she couldn’t help me since she didn’t even do surgery and immediately like I mean same day sent me to a different office to see a surgeon in her practice. She called and had it all approved through my case worker conducted an EMG and sent me on my way.  The workers comp back surgeon agreed with my private doctor that I do in fact need a spinal fusion due to the lack of disc left between my vertebrae as well as the nerve damage I have sustained. I have absolutely no feeling in my left toes the shooting pain is excruciating down my leg with any sort of physical activity and the throbbing is ridiculous anytime I’m sitting still. There really is no relief for me.  The workers comp surgeon Placed me on severe restrictions. Essentially I am allowed to move between my bed and the couch and use the toilet. The only time I am allowed to leave my house is to attend therapy doctors appointments and to meet with my attorney. So obviously the doctor understands that there is damage in my back and that I need to be careful with my activity hence why he approved my surgery.

My question to anybody that’s been through this process is do I need to be worried that Worker’s Comp. will deny my surgery?  At this point I have a recommendation from two separate doctors saying that I need spinal fusion, my concern is that Worker’s Comp. is going to deny this and drag it out and prevent me from getting the help I need. I really hope to return to work as soon as possible and would like to have the surgery and get on the road to recovery.  

 I am increasingly frustrated because I was supposed to have the spinal fusion with my private doctor today I had all my preparations in place. I had family coming from out of town to help me when I came home from the hospital, I have made arrangements for my dog to be taken care of until I was getting around better, my whole house was clean my fridge was stocked my bag was packed for my hospital stay. I was mentally prepared and now the stress and anxiety and the waiting game is really driving me up a wall 

I would appreciate anybody is inside that may have been through this I could really use some soothing words thank you

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1

Comments

  • EMS GuyEEMS Guy Posts: 1,607
    edited 06/07/2018 - 8:29 AM

    Here is what you have going for you; the doctors are in agreement you need surgery...that is huge!  If one even so much as questioned it, you would probably be stalled while the doctors appealed.  Next, you have an attorney watching out for you.  WC usually does not do silly stuff when patient's have legal representation.  It sounds like you have prepared very well for your procedure.  Having someone there to help you is critical after surgery.  A fusion is major surgery that is an assault on your body.  Recovery can seem very slow and you will get frustrated from time to time.  Just about everyone goes through that.  But, it sounds like you have your head around this and are really ready for it.  It sounds like surgery is going to happen, but understand that WC has to get everything scheduled at this point which can take a little time.  If there seems to be a delay, ask your attorney to look into it.  What companies (and attorney's) some times forget is that you are hurting while they are getting stuff put together.  Do not let all of this get you down!

    Several Epidurals, L4-S1 360 ALIF, Numerous Facet Joint Injections, RFA x2
  • L4_L5LL4_L5 Posts: 1,460
    edited 06/07/2018 - 11:35 AM

    What specific conditions are currently allowed in your claim? That should give you a good idea as to whether surgery will be approved.

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  • I’m not sure what you mean... specific claims allowed? My initial visit with the workers comp doctor listed my ankle, knee, elbow, back, hip as items to be treated. Along with abrasions & road rash essentially  along the whole left side of my body. Is that what you mean? 

  • L4_L5LL4_L5 Posts: 1,460
    edited 06/07/2018 - 1:45 PM

    Did you receive any paperwork in the mail (from W/C or the MCO) telling you what your specific diagnoses are? I’m not talking about body parts so much as specific diagnoses you received in writing.

    For example: lumbar strain.

    It’s a good thing you have a lawyer because W/C could argue your back issue is a pre-existing condition, given you had a laminectomy four years ago. Was the 2014 surgery related to a work injury?

    Don’t be afraid to call your lawyer to ask any questions.

    I doubt your lawyer will make any predictions about whether the surgery will be approved on the first try because it’s really too hard to say. 

    Like Tom Petty said “the waiting is the hardest part.”

  • All I have received from workers comp is the approval letter and two continuation letters stating I am still covered under workers comp for my Human Resources. The first doctor I saw for 6 visits did give me all paperwork he had on treating me that says “lumbar sprain” along with a few other things. The workers comp spine surgeon told me I am not allowed to have copies of the paperwork and that my lawyer can request it. 

    I did ask my lawyer what he thought this morning. He told me he has never had a client get a workers comp doctor to recommend surgery on the first appointment without having to try less invasive measures so I guess that’s good?  He also said the fact that the WC Surgeon essentially placed me on house arrest and bed rest proves that this is emergent in nature. If workers comp does deny the surgery he will petition the court and WC will have only 5 days to make a decision on if they will cover it. If they refuse I will be free to use my own insurance and after I settle with WC he would require they repay my insurance as part of the settlement. 

    Of course lawyers are notorious for unrealistic expectations but I can only hope that WC recognizes that I won’t lay down and die on this. I have done everything they asked of me to a T. And they call me daily to ensure I am indeed at home and not out and about. 

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  • L4_L5LL4_L5 Posts: 1,460
    edited 06/07/2018 - 5:23 PM

    Did you have an MRI recently that was approved by WC? 

    I’m assuming that’s how the surgeon knew what was in your best interest.

    I’m very surprised you were not allowed to have copies of your own medical records.

    If I were in your situation I’d try to get an opinion from a neurosurgeon (you may have done this already).  

    I couldn’t tell from your message if the only doctors you have seen are ortho’s.

    WC may even insist you see a neurosurgeon before they agree to cover the surgery, since you said you’re experiencing neurological symptoms.

    Hopefully that won’t be the case but WC can be very picky.

    Lastly do you know why your private insurance won’t cover the surgery? Is there a pre-existing (or work injury) clause in your policy that prevents them from covering it?

    I will consider myself immensely IMMENSELY blessed since my insurance doesn’t balk when paying for products or services related to work injuries.

  • I did have an MRI. However it was done through my private insurance prior to workers comp accepting responsibility for my injury to my back. 

    I have only seen two Ortho Spine surgeons. No nuero surgeon as of yet. 

    My private insurance only covered my medical treatment until the time I was approved for workers comp. I live in NJ and horizon blue cross denied me coverage once my employer opened the workers comp case because they said if I got hurt at work my employers insurance should be the one to pay for my treatment. My private insurance will cover me for my back but only if I provide them a denial letter from the workers compensation insurance company. So if workers comp denies my surger I can go ahead and use my own insurance and then my insurance company will sue workers comp to pay them back. It’s a crazy process! 

  • L4_L5LL4_L5 Posts: 1,460
    edited 06/07/2018 - 9:58 PM

    The MRI is probably not technically included in the claim yet considering it was done through your private insurance. 

    You may have to attend a hearing with your attorney to get the findings on that MRI recognized and allowed in your claim.

    Just a heads-up. Good luck. Please keep us posted.

  • Thank you for that information. I hadn’t considered that, I told the workers Comp surgeon I had the MRI done on my own but I will contact my case worker tomorrow so I can ask the surgeon on Monday to write a RX for an MRI to have another done if necessary to ensure it’s added to my case file. I find it so frustrating how difficult the system is to navigate even with an attorney there are so many added factors to complicate the process.

    I know many people try to use the system to stay out of work as long as possible (at least at my job) and that has made it much more difficult for people who are in debilitating pain like myself who are just interested in getting the help needed to try to get better and return to everyday activity including work. 


  • For any serious injury an attorney is necessary IMO.

    Don’t be surprised if WC denies a new MRI. They’ll probably do that to save $$ and force you to attend a hearing to get the existing MRI allowed in the claim.

    Their argument will be that if you have a new MRI done now, and the radiologist for the new MRI lists additional problems/complications that weren’t mentioned in the first MRI report, it must mean you got hurt additionally, on your own time, after the original work injury, aggravating the existing injury, for which that MRI is currently not even part of the claim (yet). In other words, Causation comes into play.

    Hang in there and do please keep us posted on your progress. You’ll come out a much stronger person for having gone through this.

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