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Insurance Hell All insurance-related matters are here: Medicare, worker's compensation, appeals, denials, insights, wins, losses. PRICING is here too. Note: This forum has posts from 2006 forward. Older ones are in the Big File.


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Old 09-25-2016, 05:32 PM
GirlCaptain GirlCaptain is offline
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Default Worker's Compensation authorized 2 level Mobi C

Hello all,
Hopefully my recent experiences will give others some guidance and some hope to get authorization for ADR. I was recently the 1st 2 level ADR authorized by any insurance to have the procedure at UC Davis Medical Center in Sacramento, CA. I was an 8 year old workers comp case in which every other intervention had been tried, multiple times. This played a large part in my getting authorized, because I had exhausted all conservative therapies, and was well past the Worker's Compensation 12 week window to default to chronic pain management after a back injury.
Let me back up a bit- In California, worker's comp is governed by Law by treatment guidelines from ACOEM- the American College of Occupational and Environmental Medicine. If you have a cervical spine injury like mine, the treatment guidelines allow you 12 weeks of "conservative" therapy. If you're not all better by then, you fall under the "Chronic Pain Management" guidelines, wherein they recommend Tylenol. Nope. Not kidding. The current treatment guidelines for cervical spine injury that are adopted by state law were written in 2004 . Obviously ADR wasn't an option then, but it is according to the latest set of ACOEM guidelines , published in 2011. This recommend ADR for cervical spine patients with chronic radiculopathy.
I was very lucky- I think that the surgeon who reviewed my request for ADR knew that the guidelines would be changing when the state government got around to updating that particular law, and didn't make me jump through the hoops and appeal. Also, the folks at UCD did a bang-up job writing the request for authorization, including all the pertinent facts in their letter. So, The take-home lesson here is two-fold. 1) make sure your request for authorization or your appeal is incredibly well written, and includes cervical radiculopathy as one of your primary diagnoses. 2) BE ready for a fight, armed with the latest ACOEM guideline which can be found at the website for the National Guidelines Clearinghouse.

There are other pertinent portions of the California Labor Code that I'm familiar with that can be brought to bear if the 2004 version of the guidelines are used to deny ADR. If anyone has any interest in hearing about that or needs help with just such an appeal, let me know and I'll share all that I've found.

Best of luck everyone- It can be done, and you can get better!

GC
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52 year old female, retired Fire Captain
Whiplash injury in early 20's, years of wearing
leather fire helmets, run down by a car 2008
Herniated Discs C5-6, C6-7
Thoracic outlet syndrome, cervical radiculopathy,
cervical myelopathy
Had 2 level ADR with Mobi-C at UC Davis Medical Center on 9/14/16.
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Old 09-25-2016, 09:41 PM
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Fathub Fathub is offline
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GC
Wow......somebody spent a TON of time and organizational prowess. Thanx a lot for blazing some new trails....
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Dec 1/15 - 3 level ADR from S1/L3 c/w 360 mobility preservation at L3/L4 for Spondylolisthesis done by Dr. Bertagnoli in Bogen GmbH.
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