Found out more today re spine surgery requests for authorization going thru UR process in CA.
First time goes to Spine surgeon for authorization.
If denied, surgeon that will be doing surgery can rebutt with scientific evidence (EBM), studies and so forth, treatment plan...
IF still denied ..
If turned down, appeal goes to group/panel of Spine Surgeons.
If denied here, goes to Arbitration.
Here is where the Insurance Co. stands to lose $$ if it's found that they are denying treatment as Penalties are attached and can be very significant.
** I once got to this point in my treatment w/lifetime future med benefits over an unpaid $500 pysch bill after my failed back surgery and the judge ruled in my favor to the tune of $7,000.
Arbitration is binding so decision rendered stands...
This is just a skeleton sketch ... mostly what I was told is if and when you go to Arbitration, you should have an attorney representing you as the package that is put on the table in terms of why one wants the surgery done almost has to be put in more in legal jargon than medical in terms of what the person stands to lose if the "prescribed treatment or care" isn't rendered... Still there has to be solid information (case) backing the request package for the desired treatment or surgery, procedure (whatever)..
*** I wanted to add that I remember there was a person at this forum who is a WC attorney, I'm sure he could give the "real deal" of what is entailed in this process, however, I'm going by what I've read at workcomp websites and what the Nurse Case Manager told me of the appeals process.
So if there is anyone out there that wants to clarify or correct anything, please do so~
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