Q: Work Comp Peer Review says surgery, but they won't approve pre-auth for it. What do I do?
I work for a school district and fell on campus. Over time my injury was getting worse, even though I sought treatment that day and months after. TASB had a peer review done that agreed my injury was likely caused by a fall and that surgery was recommended. After working with my dr to remedy the injury less invasively, surgery is now what my dr wants to do. When they submitted for pre-auth, TASB is denying. Appeal was also denied. IRO has been filed, but what are my options going forward? How can they say surgery is recommended yet deny it when the time comes?
A: The adjuster on your file does not have medical training so whether the surgery is reasonable and necessary is subcontracted out to medical specialist that determine whether the requested procedure meets ODG guidelines. If the LHL-009 (Request for IRO) is not successful, then I would recommend you put the procedure on private health. You do have the right to have a hearing but these are almost never done due to the difficulty of actually winning after the IRO says your surgery is not reasonable.
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