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  1. #1
    Join Date
    Nov 2012
    Posts
    18

    Default Surgery is Medically Necessary but Workers Comp Won't Pay

    My workers compensation claim was made in the State of: MA

    Hi folks, been on workers compensation just over a year with a serious back injury that two surgeons have deemed medically necessary.

    But attorney is saying that insurance company can opt not to pay for the surgery...???

    Any way someone can help explain this to me?... Attorney simply suggested i wait to see if the adjuster approves it with the doctor (what the heck does this mean?)

    hope to hear from someone!

    thanks

  2. #2
    Join Date
    Sep 2008
    Posts
    148

    Default Re: Surgery-Medically Necessary

    It means find a new attorney! I have been fighting for over 4 years now for back surgery and my first 2 attorneys had the same attitude as your attorney and nothing ever got done, now on my third attorney and things are beginning to move at last.

  3. #3
    Join Date
    Aug 2011
    Location
    san antonio tx
    Posts
    109

    Default Re: Surgery-Medically Necessary

    1st depending on what the insurance comp is saying they are accepting, are you at mmi yet? if you have a md that says surgery needed these a- holes will send you to an RME to discredit the md that says you need it, the ins have they had a designated doctor tell you all you have is a sprain strain? they are good for that. but it makes me uncomfortable that atty isn't a little more forthcoming, they certainly know how to submit their charges and get you locked in with them. So, even if you wanted to get new atty sometimes it's hard. So, first check on your mmi and what your diagnosis is..Thanks Ann

  4. #4
    Join Date
    Nov 2012
    Posts
    18

    Default Re: Surgery-Medically Necessary

    hi vanilla... what's mmi?

    i've been to 3 IMEs and they've all sided with me... diagnosis is 3 herniated discs and a stress fracture... surgery would involve fusions with instrumentation and a gill laminectomy

    and the medical doctor they sent medical records to was one hired by the insurance company

  5. #5
    Join Date
    Aug 2011
    Location
    san antonio tx
    Posts
    109

    Default Re: Surgery-Medically Necessary

    Hi, For me they put me at MMI almost 3 months after my injury so they would not have to pay anything but here is the definition
    Maximum medical improvement (MMI) occurs when an injured employee reaches a state where his or her condition cannot be improved any further or when a treatment plateau in a person’s healing process is reached. It can mean that the patient has fully recovered from the injury or that the patient’s medical condition has stabilized to the point that no major medical or emotional change can be expected in the injured workers’ condition. At that point, no further healing or improvement is deemed possible and this occurs despite continuing medical treatment or rehabilitative programs the injured worker partakes in. When a worker who is receiving Workers' Compensation benefits reaches maximum medical improvement, his or her condition is assessed and a degree of permanent or partial impairment is determined. This degree will impact the amount of benefits the worker is able to receive.

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