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Help!! Workers Comp denied Lumbar Fusion...

TrixieMamaTTrixieMama Posts: 64
edited 06/11/2012 - 7:52 AM in Back Surgery and Neck Surgery
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 :)



  • Beware of the workmans comp rep that you think is helping you remember she is working for your employer and not for you. They make you feel like they are helping you but the are NOT..... Get a attorney. I have been dealing with the same thing for 5 years and it only gets worse if you don't have someone with the knowledge of the laws. Sorry to be the bearer of bad news but dealing with workmans comp is no fun. Hope everything turns out ok for you
  • Call the rep on Monday. Is this a adjuster or a nurse case manager? You have the right to appeal the decision and admit the proper information. Also you should have the right to a second opinion which I would do and get that information on the appeal. But first try and work it out with them. If this person is going to appointments with you I wouldn't let them in the examine room they can get the opinion once the exam is over and you hear it at the same time. Also be sure you have copies of the doctors reports and know what they have written. Be sure one of those records don't indicate that information.
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  • Thank you. I will likely have to go the route of an attorney at this point. This is the first big speed bump i've had. It's unfortunate. Thank you for your reply :) I am sorry to hear you have been dealing with this for so long. It's such a trying experience and i've only been through it for 5 months. Good luck to you and God bless <3
  • I don't know who my nurse case manager is. They keep changing adjusters and case managers. No one has gone with me to any appointments, it's just the MD and myself. The person I referred to is just the workers comp rep from my work. She just checks in with me anytime anything comes across her desk from the MD such as upcoming appts or authorizations. Any communication problems i've had with the insurance carrier she has resolved.

    I know that she works for my employer and her job has a vested interest in getting my case closed as quickly as possible. All things considered, it hasn't been very bad because she has quickly handled any issues that have come up.

    I am scheduled for a second opinion mid May, that was the soonest they could see me. The MD I am seeing had to refer me to another MD as I requested a second opinion a month ago. The second opinion MD is busy though and can't fit me in until May.

    I only have a copy of my MRI but will call Monday to the clinic and request a full copy of my chart. This whole process is so overwhelming. I was totally blind sided by the denial and the fact that it included wrong information as well as omitted important information.

    Thank you for your advice :) I appreciate the time you've taken anytime I post to help me. Have a blessed day <3
  • Kimberly,

    Having retired from the federal government, and as a supervisor having to see the crap my employees went through....

    I would still call the rep as you mentioned, I would also contact my doctors as well! Explain to them what is going on. Sometimes it only takes a letter of clarification to get this snafu fixed. If the treating physician is saying "surgery", and they have the facts vs whatever info they have now, things can and do get cleared up, but get the doctor involved.

    Please let us know how it goes. So sorry to hear of another person in the OWCP web of hell!!

    PCTF C4 - T2, Laminectomies C5, C6 & C7. Severe Palsy left arm/hand.
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  • I too was injured on the job, knocked unconscious by a snowboarder (I teach skiing to kids) which resulted in a concussion, bruised kidney, moving my SI joint to a different time zone and torn cartilege in both knees. At first the workers comp company (a private company) was great and paid for everything. As it took years for the spine to start degenerating I eventually got new claims rep who was the sister of the wicked witch of the west. They stopped paying for my meds and said my condition was due to my age (I was in my late 40"s). They were still paying for PT and prolotherapy. Then I got the letter that says the company was in receivership and my benefits would stop. By then I had moved to another state. I did not have the funds to travel back to the state where the accident happened and hire a lawyer. Eventually the letter came that said the company was bankrupt but would pay me a small amount and I would give up all rights to any more money. I figured since they had no money and were bankrupt this was my only option. Looking back I don't know that that was the best decision but again, taking time off work, traveling, paying for accomodations and hiring a lawyer just wasn't in the books. Since then I have had 4 surgeries, one laminectomy and 3 fusions.I am fused L1 to S1. The impact really destroyed my lower spine. Thankfully I have good insurance at work and my out of pocket has not been astrommonical. I just say it is not accident caused. Talk to an attorney. There are good WC attorneys and in another case I got the action to pay nothing reversed. Good luck!!!


    Spinal stenosis, spondolysis, spondolythesis, L4/L5 laminectomy, L4/L5 360 fusion with instrumentation, L1 to L5 fusion with instrumentation and bone graft from hip, L1/S1 fusion with replacement disc put in, PT, accupuncture, prolotherapy, many cortisone injections, 4 rhizotomies. Currently on tramadol which barely touches the pain.
    L4/L5 laminectomy, L4/L5 360 fusion with instrumentation, L1 to L5 fusion, L5/S1 fusion w/ disc replacement, left and right SI joints fused.
  • Workers comp his handled differently in every state from one another. Have they exhausted every form of conservative treatment?

    Typically, WC wont approve surgery unless conservative treatment is not effective. Plus, they want to make sure you are "compliant" with what the doctors request you go through.

    Hate to say it, but WC can be a nightmare to go through. I was pretty fortunate to make it through everything without a lawyer. The laws where I live are not difficult. Other states are much worse. The best thing you can do at this point is to educate yourself to the WC law where you live. Document everything!

    Several Epidurals, L4-S1 360 ALIF, Numerous Facet Joint Injections, RFA x2
  • Is the WC a state company or were you employed with the Federal Government. The two different "kinds" of WC are both very different. I can give you some insight into Federal Workers Comp but have no idea about the other. Sorry you are having such a hard time. Usually - I think - WC hopes that you give up...so don't. Re-group and keep calling, writing, faxing or whatever you can do.
  • Thank you to all who responded and for all the wonderful advice :)

    Yesterday I spent the day on the phone with the insurance company (private co, not state/federal) and was basically told that it didn't matter that the denial was riddled with errors, it was still a denial and they wouldn't do anything about it.

    At first they refused to resubmit it for review since I wasn't sure they had even looked at my correct file BUT.... after telling them that it was obvious they didn't have my best interests at heart and that I needed to look out for myself by consulting legal counsel, they called me back and sang a different tune. It still was out of key and they attempted to deny me my rights so today I hired an attorney.

    Unfortunately they decided yesterday to turn it over to the state citing it was mandatory under the law because regardless of mistakes it was still a denial so my denial is being forwarded with the wrong information to the state for review. They also cancelled my second opinion I had scheduled for three weeks and said I couldn't have it and had to wait for an Admin board to assign me a state appointed doctor. They made it clear that I had no choice and could not select an in network doctor because of the denial.

    The things I was told yesterday blew me away.

    So, now I sit and wait while my new attorney works out the kinks and gets this whole thing straightened out. They will get me my second opinion. Spoke also with my treating surgeon too.

    Thank you again for all your help and support. It is such a blessing to know that I am not alone in this and can not only come here to seek support for my back issues but also for WC help.

    You guys ROCK!

    HAve a blessed day <3
  • Do you have private health insurance though your job? If so check with them and they have to pay if the wc is denied. Your private insurance would then get reimbursed by wc.
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