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  1. #1
    Join Date
    Oct 2010
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    10

    Default Appealing Non-Certification After Ur Review

    Hi Everyone,

    I just needs some help with procedure (steps to take, paperwork to file, etc). I have a future medical award on a WC case. Recently my doctor sent a request for authorization of a particular treatment to the adjustor who sent it to utilization review. UR recommended non-certified. I am now waiting for my surgeon to do a consult with the UR doctor. Does anyone know the steps I need to be taking in case it is denied again? I am quickly losing optimism about the process.

    The injury is straightforward and there is no causation issue.

    Thank you in advance for any info!

    Ava

  2. #2
    Join Date
    Feb 2007
    Location
    Calif
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    Default Re: Appealing Non-Certification After Ur Review

    The injury is straightforward and there is no causation issue.
    Doesn't matter.
    You have a Stipulation w/Request for Award, or a Finding w/Award and Order from a WCAB judge.

    As such, the medical access to your injury is the same process as prior to the Stip.
    PTP request for treatment, CA autho, or refer to UR for decision.
    As you said, your PTP has the first appeal...but at the same time, you have to notify the CA, in writing, of your intention to dispute the UR decision under section 4062 of the labor code. That info should be contained in the last page of the Provider Notification Notice you rec'd advising you of the delay/denial. You have 20 days from the date you rec'd the letter.
    Send your intent in writing, USPS return receipt requested.

    Labor Code 4062 is here http://www.leginfo.ca.gov/cgi-bin/di...file=4060-4068 use the section based on your status... with or with out attorney.
    The Title 8 CCRs on UR process are here http://www.dir.ca.gov/t8/ch4_5sb1a5_5_1.html

  3. #3
    Join Date
    Oct 2010
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    10

    Default Re: Appealing Non-Certification After Ur Review

    Quote Quoting BvIA View Post
    Doesn't matter.
    You have a Stipulation w/Request for Award, or a Finding w/Award and Order from a WCAB judge.

    As such, the medical access to your injury is the same process as prior to the Stip.
    PTP request for treatment, CA autho, or refer to UR for decision.
    As you said, your PTP has the first appeal...but at the same time, you have to notify the CA, in writing, of your intention to dispute the UR decision under section 4062 of the labor code. That info should be contained in the last page of the Provider Notification Notice you rec'd advising you of the delay/denial. You have 20 days from the date you rec'd the letter.
    Send your intent in writing, USPS return receipt requested.

    Labor Code 4062 is here http://www.leginfo.ca.gov/cgi-bin/di...file=4060-4068 use the section based on your status... with or with out attorney.
    The Title 8 CCRs on UR process are here http://www.dir.ca.gov/t8/ch4_5sb1a5_5_1.html
    Thank you for the response and all of the information. I guess I did not make my question clear enough. First, I only put that causation was not an issue because I didn't want any responses to be sidelined on the medical/legal aspect of the claim (which I have no questions about) and I wanted to keep me question short and to the point. Second, I am aware of the appeal process (peer to peer consult/20 day written objection, etc). I am just not sure of the procedure if this appeal is denied. I know the next stage is QME, but not sure as far as papers to be filed for this, etc. Hope that is clearer. Possibly I already know all there is to know about this, but I was hoping there might be something.

  4. #4
    Join Date
    Oct 2010
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    10

    Default Re: Appealing Non-Certification After Ur Review

    I tried to reply to this at length, but it didn't post. Just trying again to see if it works...

  5. #5
    Join Date
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    Calif
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    Default Re: Appealing Non-Certification After Ur Review

    There is a cap on words on this board...when you do post, please be sure to break up a huge block of print...just hit the 'enter' key twice...thanks.

  6. #6
    Join Date
    Oct 2010
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    10

    Default Re: Appealing Non-Certification After Ur Review

    Thank you for the info (both workers comp and forum posting advice!).

    When I mentioned "causation is not an issue" that was only because I didn't want to distract from the question I was asking by seeming to solicit medical/legal advice and/or going into lengthy history of my injury. It seems that in trying not to distract, I just distracted...

    Anyway, I know about the appeals process already but I have a feeling my appeal will be denied. I know the step after that is QME, but my question was more about how I go into that phase (filing etc) and if anyone has any generalized knowledge on how long it takes?

    Just disappointed because, per the doctor, the injury is treatable. If WC denies the treatment, I am afraid they will expect me to be on pain meds and non-functional ad infinitum, rather than just fixing the problem and being done with it.

  7. #7
    Join Date
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    Location
    Calif
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    Default Re: Appealing Non-Certification After Ur Review

    my question was more about how I go into that phase (filing etc) and if anyone has any generalized knowledge on how long it takes?
    If the UR Dr denies, there must be info on how to dispute under the labor code 4062, you just write a letter to the CA. At the same time, ask for the form for requesting a PQME from the Medical Unit. Or, go to the DWC site, and the form will be there. http://www.dir.ca.gov/dwc/forms.html
    Med Unit doesn't take long to provide the panel, you have 10 days to select a Dr to act as PQME to resolve the disputed issue.
    How long it takes to get an appt is up to the Dr/PQME and their scheduling. A report should/must issue within 45 (working) days. If not, you can request a new PQME to perform a new evaluation.
    Just disappointed because, per the doctor, the injury is treatable.
    If that's the case, your PTP shouldn't have difficulty providing the MTUS/ACOEM treatment guide, or other EBM/Evidence Based Medicine to support the request and recommended treatment plan.
    If WC denies the treatment, I am afraid they will expect me to be on pain meds and non-functional ad infinitum, rather than just fixing the problem and being done with it.
    WC is not medical or health insurance for the employee/IW. The recommended treatment must be "reasonable, and necessary to cure or relieve from the effects of your injury/illness".
    Any/all treatment is not generally provided. Requests are handled on a case by case basis. What your PTP recommends for you, and maybe another IW, may be the same, where one is approved and the other not.

    Just don't miss your timeframes or you could forfeit benefits, and have to start anew.
    When I mentioned "causation is not an issue" that was only because I didn't want to distract from the question
    Once you have met the AOE/COE challenge, and a accepted claim....there is no issue of "causation" to the injury, no one disputes you are injured.
    Causation would be addressed once you are MMI, and apportionment to cause of PD is considered.

  8. #8
    Join Date
    Oct 2010
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    10

    Default Re: Appealing Non-Certification After Ur Review

    Thanks for all the info. I really appreciate your time in responding.

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