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  1. #1
    Join Date
    Feb 2012
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    12

    Default What Happens Next, After a 25 Minute AME Appointment

    I was injured in 2008. Neck injury to the c-7-8 area, 7 months later from lack of the right treatment I got a bad case of fibromyalgia my bones are killing me along with spasms etc. & they want me to think i am colored is what they say in physicatric terms they say. Pain ya that would affect anyone. Because of a crushed nerve that showed on a nerve conduction test. X-rays is for the bones, MRI for the tissue, &. Myleogram I needed is for the nerves. Now the neurologist won't request because he says it's not reversible now because it is through my nervous system. I possible have rsd 1 & every request for treatment is denied. Including a pump for pain. They said I was ps when I was not. The doctor told them I am not. I had and attorney that disconnected his number cannot find him, he did not submit any paper to the ame on my behalf. The ame saw me for 25 min, talked then had me walk the haul stand on toes & heels I could not. Tryed to turn my head, which I could not. He rated me 8 % , requested injections that I've had in the past & do not work.Please if anyone can help with what to do now, I could use your help. If there is anything left to do ?

  2. #2
    Join Date
    Oct 2006
    Posts
    9,108

    Default Re: What Happens Next, After a 25 Minute AME Appointment

    once both parties have the report they can negotiate a settlement or file for a court date.
    in the meantime you should look for another atty.

  3. #3
    Join Date
    Feb 2007
    Location
    Calif
    Posts
    18,011

    Default Re: What Happens Next, After a 25 Minute AME Appointment

    P&S/MMI means your condition is stable, or Max Medical Improvement has been reached, your condition is not expected to change better/worse in the next 12 months. With or without treatment, this does not mean further treatment won't be provided.
    Because of a crushed nerve that showed on a nerve conduction test. X-rays is for the bones, MRI for the tissue, &. Myleogram I needed is for the nerves. Now the neurologist won't request because he says it's not reversible now because it is through my nervous system.
    Your PTP can, and should refer you to pain management Dr. Get the referral, and you can change PTP to the PM Dr.
    Those tests you mention are used to diagnose, and determine if you are a surgical candidate. They won't be approved "just because" to see how you are doing.

    AME is a medical/legal evaluation, there are face/face time requirements, depending on the type of injury, but the bulk of the report is based on medical records review. Not necessarily face/physical evaluation time.

    You can file a dismissal of your atty with the WCAB, go to an I&A officer for help, or find another atty to take over the claim...www.caaa.org for names in your zip code.

    You can negotiate a settlement, Stipulations w/Request for Award would provide for future medical. You could also file a DOR/Declaration Of Readiness to proceed and go to MSC/Mandatory Settlement Conference, if no informal agreement can be reached, you go to trial. A WCAB judge will issue a finding.
    You can submit the AME report to the DEU/Disability Evaluation Unit for consulative rating. That is the only PD/WPI rating a judge would rely on.

    There are no more TTD benefits to be paid, only 104 weeks are provided. If your PTP determines you are still unable to work, you should apply for SDI, State Disability Ins benefits could pay an additional 52 weeks of disability benefits.

  4. #4
    Join Date
    Feb 2012
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    12

    Default Re: What Happens Next, After a 25 Minute AME Appointment

    Can you dispute and ame's rating to be revised.He said that I do not have rsd 1 without even checking me . After getting blood work back today he was wrong. Working on the attorney thing. thank You

  5. #5
    Join Date
    Feb 2007
    Location
    Calif
    Posts
    18,011

    Default Re: What Happens Next, After a 25 Minute AME Appointment

    If/when you have additional medical evidence that was not available at the AME evaluation, you can get a supplemental report.
    If these issues are outside the field/scope/specialty of the Dr AME you saw, you have grounds to challenge the report, and get another Dr, or AME to opine on the issue. Not all neuro/ortho Dr are specialists in RSD, that would take a Pain Management specialty.

  6. #6
    Join Date
    Feb 2012
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    12

    Default Re: What Happens Next, After a 25 Minute AME Appointment

    Now with all this going on with the ame. My doctor is tired of requesting treatment for blood tests,bone scans, pain management doctors etc. because the insurance keeps denying everything. With the ame's request for treatment the Insurance denied his treatment options any good advice ?

  7. #7
    Join Date
    Feb 2007
    Location
    Calif
    Posts
    18,011

    Default Re: What Happens Next, After a 25 Minute AME Appointment

    With the ame's request for treatment the Insurance denied his treatment options any good advice ?
    When you see an AME, it's to resolve a disputed medical issue... AME does not 'request' any medical treatment.
    If your PTP has requested treatment through the UR process... and denied, you see AME, IF the carrier disputes the AME, they must file a DOR for MSC/expedicated hearing on disputed medical issues.
    My doctor is tired of requesting treatment for blood tests,bone scans, pain management doctors etc. because the insurance keeps denying everything.
    It doesn't do any good to keep sending in the same request if the PTP isn't providing the appropriate ACOEM/MTUS, or other EBM/Evidenced Based Medical protocol to support the treatment requested.
    The UR process takes max of 14 days (but for prospective review in some cases), there is no reason your PTP should be "tired"... change PTP.

  8. #8
    Join Date
    Feb 2012
    Posts
    12

    Default Re: What Happens Next, After a 25 Minute AME Appointment

    I told my neurologist that I want a second opinion today. I went to see the other neurologist he said only if he refers me can i go to him. He just shook his head and said we will do our best to help you it's unfortunate they have waited so long for what could of been and easy fix in the beginning. They denied me switching treating physicians early on that my current neurologist requested who is my treating physician as well.How do I get to a treating physician I want? What do I do if he denies my request for a second opinion that I will be paying for?

  9. #9
    Join Date
    Feb 2007
    Location
    Calif
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    18,011

    Default Re: What Happens Next, After a 25 Minute AME Appointment

    There is a specific process in place when a PTP recommends spine surgery. And it's not going around to different surgeons to get another opinion.
    He just shook his head and said we will do our best to help you it's unfortunate they have waited so long for what could of been and easy fix in the beginning.
    IMHO... that is unfortunate for any Dr to tell a patient that... there is NO way, even for a DR to tell what your condition may have been 7 months or a year before seeing you. Now you have it in your head you were not provided adequate medical care. No Dr can use his "esp" to tell you that. There is no guarantee you would have been "fixed" either.
    They denied me switching treating physicians early on that my current neurologist requested who is my treating physician as well.How do I get to a treating physician I want?
    You don't need prior authorization to change PTP... all you do is select from the MPN list, make an appt and see the new PTP. That's why there are MPN's in place in the first place.
    4061.5. The treating physician primarily responsible for managing
    the care of the injured worker or the physician designated by that
    treating physician shall, in accordance with rules promulgated by the
    administrative director, render opinions on all medical issues
    necessary to determine eligibility for compensation. In the event
    that there is more than one treating physician, a single report shall
    be prepared by the physician primarily responsible for managing the
    injured worker's care that incorporates the findings of the various
    treating physicians.
    If your PTP wants to make a referral to another Dr/specialty, there are provisions for that too... however a Neuro would not make a referral to another Neuro... he should know what he's doing.
    What do I do if he denies my request for a second opinion that I will be paying for?
    Why would you be concerned with a denial on seeing a Dr you would be paying for out of your pocket ?
    Any Dr who denies a second opinion...IMHO, should be dropped from treating you.

    Second opinion spine surgery....SOSS process is described in section 4062
    Employer objections to the treating physician's recommendation for
    spinal surgery shall be subject to subdivision (b), and after denial
    of the physician's recommendation, in accordance with Section 4610.
    If the employee objects to a decision made pursuant to Section 4610
    to modify, delay, or deny a treatment recommendation, the employee
    shall notify the employer of the objection in writing within 20 days
    of receipt of that decision. These time limits may be extended for
    good cause or by mutual agreement. If the employee is represented by
    an attorney, a medical evaluation to determine the disputed medical
    issue shall be obtained as provided in Section 4062.2, and no other
    medical evaluation shall be obtained. If the employee is not
    represented by an attorney, the employer shall immediately provide
    the employee with a form prescribed by the medical director with
    which to request assignment of a panel of three qualified medical
    evaluators, the evaluation shall be obtained as provided in Section
    4062.1, and no other medical evaluation shall be obtained.
    http://www.leginfo.ca.gov/cgi-bin/di...file=4060-4068

  10. #10
    Join Date
    Feb 2012
    Posts
    12

    Default Re: What Happens Next, After a 25 Minute AME Appointment

    Thank You ,very helpful. I am concerned because my ptp has not been helping me to get adequate treatment with this denial from him I cannot pay for the apt. Because the doctors will not see me without the referal so the doctors notes and my medical records can be transfered. Same with switching ptp. That's what they said to me. I had a ppt that was a wcomp doc fought for everything to help me. After going to the neuro and having and + nerve conduction test, they dropped the wcomp doctor & would not let me go back. Would, I go to the wcomp office for the papers? Monday, I have some work to get done.
    Last edited by Lattegirly777; 02-09-2012 at 10:44 PM. Reason: Forgot question about wcomp

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