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Workers Comp and Carrier not allowing anything

Lower back injury 2012.  SCS tried in 2015, removed in 2016 causing more pain...    I settled my work part of this in 2018 and kept medical open.   Ever since we did this, the Carrier denies any and all procedures and Comp is refusing to schedule a hearing..  My lawyer is bending backwards on this and he can't get it done either...   Last MRI done was in 2017... surgeon has tried 3 times to get a new one to compare and see how much more the damage is.. all 3 were denied due to Not Medically Necessary.

I am about ready to just say the heck with it, office visit my lawyer and tell him I want to settle medical.. but I'm not settling for a low number...   4 discs involved... 2 blown, 2 bulging, pinching all the nerves which causes pain from hip to hip.  Right hip is about gone because of the way I walk now and the right leg is constantly numb... I am now told to try and stay off stairs because of this and from the fall down some last October.

Has this ever happened to anyone else?  Medicare and Aetna know this is a comp claim and won't touch it.  But I can't believe I'm being denied for everything..




  • L4_L5LL4_L5 Posts: 1,441
    edited 06/17/2019 - 2:31 PM

    Can you submit your WC denials to your insurance? Usually when WC denies a procedure you can send the denial paperwork to your private insurance and then they’ll cover the procedure.

  • CLB, L4L5 is correct, under the affordable care act, pre existing conditions are covered under your regular insurance. As L4L5 advised, include your denial letters from W/C! Do not settle out on your W/C. 1 back surgery is expensive! You need to have a talk with your W/C attorney and have him get to the bottom of it! ....David


    Veritas-Health Forum Moderator

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  • Have been in contact with my lawyer...  He has told Comp of all the denials... 6 injection denials for Pain Management and 3 MRI denials from my new surgeon.   I have tried before asking Medicare and my insurance if they would cover any of them and they refuse.  They told me as long as my medical is open, they won't touch it.   I was in the ER in October from going down my cellar stairs cause my lower back and legs went numb...  ER billing sent it to my insurance and they denied it and had them send it to the carrier..  This carrier has even denied medications...  Adjuster always says it's not medically necessary...   Here in the middle of NY, it's hard to get a lot done...   I see the surgeon on the 26th and see if he can re-word the request for a 4th time or even put in for injections...   But all this is causing a lot of stress which brings out the depression.....

    Thanks for posting some help.....  I will also talk to my lawyer about demanding a hearing.

  • I’d be contacting the governor of New York and/or the representative where you live. 

    Ask your lawyer if he can help you and if not ask him “am I going to have to write certified letters to my representatives and the governor to get action on this?” 

    It sounds like you’re in an usual predicament. I’d ask the lawyer to explain in detail why what’s happening is happening.

  • @CLB   

       I am going threw the exact same thing..see with medicare and private insurance it's more then just the wc insurance company denying you. You have to be flat out denied by the without a hearing in front of the commissioner and the commissioner denying you too Medicare and private wont touch it. Once the state also deny it..then you can use Medicare and private and they will put a lien on any future settlement you recieve. So in reality it's just a temporary fix cause in the end Medicare will get their money back.

       See I too am open medicals but I also havent completely closed the rest out too but am in the same spot...what needs to be done is YOUR lawyer not the insurance company needs to file issues for a hearing..your lawyer needs to fight for your care..but then again we are talking the lawyer needs to invest both time and money to get it done and without a $$ for them they may not want to even file for you.. but you can file for yourself..might shock everyone into action.

     EMTGUY on here is a wonderful person to speak with as hes handled his case alone..also since I'm going threw the exact same thing have any questions I'm a message away.

       I have a upcoming hearing myself on getting treatment as well as a ton of milage the wc insurance company seems to not want to pay..but you've got to get you Lawyers butt moving cause the insurance company is just going to keep denying you. I'm sure your lawyer will suddenly show interest if he smells money..its sad it really is sad.

       Settling out your medicals isnt as easy as you think either..again Medicare will be involved and there must be a set a side or a allotted amount of money put a side which must be spent on medicals only before Medicare and your private insurance will take over.

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  • boo9989bboo9989 Posts: 583
    edited 06/18/2019 - 11:21 AM


       Lawyer make most of their money during the PPD phase of your wc..beyond that they really dont get much so it 1 reason lawyer during this phase lack motivation 

  • Just an update....  surgeon sent me to another place to see what they can help with...  PA was  appalled with what we told her about Carrier and Comp..   She is putting in for a EMG on the lower back and right leg.  Also on Meloxicam 7.5 twice a day..  We are taking bets that both will deny this.. plus the request for injections and that MRI..  Surgeon has put in request #4 too...  PA says I need that MRI to compare to the last one in 2014 to see how much worse the damage has gotten..She had me close my eyes and ask if I felt her touching the legs...  left I could, but not on the right.. the leg can be that numb...   Then asks what I use besides a cane when I can...  I own a wheelchair... She agrees with my surgeon... if the discs are not taken care of now, I'll be in that wheelchair sooner than later...  So we are hoping the medication will help with the swelling and some of the pain until they can have anything done...

  • @CLB

      I know it's horrible and believe me I feel for you. I've been going there the exact same thing . Limbo Land..

      I was just dragged threw yet another ime back in May my 3rd in a year and a half..they know they got me right were they want me..I'm stuck..cant use my own health insurance because medicare wont allow it. It doesnt matter if you've only got part A or full medicare..medicare is a government healthcare so it will always be what in their best interest. Even if you manage to get fully denied by workers comp and medicare let's you move forward they will put a lien on any future money you get out of workers comp as repayment. 

      Like I said I've been sitting here rotting away trying to get help..I do have a upcoming hearing with comp so hopefully I can finally get the medical care I need..

      Has your lawyer spoken to you about possible settlement? Unfortunately again Medicare will have a big say in that and will require a set a side which could take any money you might recieve out of the picture entirely. But atleast you can then get the needed help..I'd suggest and this is from my own experience you go up on the Medicare site and read up on all that's involved and what medicare requires..hope you can get the help you need and dont end up rotting away like I am..


  • Boo.. we are waiting to hear if I'll get the EMG denied.. if that happens, then off to lawyer's office I go..  I just wish I could hire another lawyer to sue the Insurance Carrier for all this pain and suffering and the fact they won't allow anything to be done.     When the med was put in, the store just stuck it under my private ins.. They'll never know cause I'm being seen for this 2017 neck surgery.... and besides.. it was only 2.00.....

  • @CLB

      God...your having almost exactly the same issues as I many dont understand. I wouldn't wait..I'd still get a lawyer atleast to help you if you plan on settling out or even just to get the ball rolling... More then likely if your doctor request alot of test you will have to go to a IME ..that's what my carrier keeps doing to me..its like their stall and delay game...or they may just not acknowledge your doctors request at all..another thing my carrier likes to do.

       May I ask why you havent gotten a lawyer yet ?  You have some serious issues you certainly would benefit from one. No up front money is involved.  I'd atleast call a few ...most if not all give free consults too..and their fee come out of any settlement they get for you so no upfront money ..its going to be really ruff without one. But I do hope yours is a temporary blip and thing get better for you. Me I'm off to a hearing soon unless they decided before the hearing to allow me my second opinion on surgery. 

      Keep me posted on how thing are doing ..

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