Need Help~

[Mariaa]

I cannot post over at Braintalk/ Workers Compensation Forum and am wondering if anyone here knows this info or could post it for me at Braintalk so I can get a reply.

I have a Primary Treating Physician. Have been seeing him for nearly 9 years now. Never had surgery with him although he has proposed multi-level fusion until recently and of late, proposed fusion at L5S1 and Charite ADR at L4~ if L3 is ok on the discogram (and other lumbar discs).

WC insur. several years ago sent me to the Spine Center/Santa Monica (in '04) and at this time I could have had a 2 level ADR Prodisc done during trial but was afraid.

When I became ready to have this surgery I was notified I was no longer able to get it since new CA. WC laws in effect and UR non certifying surgery so WC insur.carrier could no longer just offer to pay for it.

After my treating OSS said he wanted to do a fusion at L5S1 and Charite implant at L4, I was not sure of the fusion part (still hoping for multi-level ADR). WC insur decided to send me to a surgeon in San Diego (OSS) who doesn't do ADR but his recommendation was for a 2 level ADR at the Spine Center/Santa Monica so I was sent back there with same surgeon for 2nd consultation.

The surgeon also thought a fusion at L5S1 would be best so as not to distract the L5S1 area too much and cause more nerve pain than I already have (hopefully).

He was advised to send his request for authorization for surgery to WC.

Instead he sent a summary of the visit more or less. Indicated I am a very nice lady he has seen for the 2nd time (thank you doctor). He made no mention of a discogram to make sure the rest of the lumbar spine wasn't concurrent for pain, and in the very end of the summary he wrote "the prodisc replacement for one level will be approved in April and certainly I would wait until thie approval came through."

Ok, here's the deal~ the Claims Adjustor is telling me that I should go back to this OSS in San Diego so he can write an "admissable" report and send it to UR. He says he cannot send what the surgeon wrote to UR as it would be torn to pieces (but the Claims Adjustor did sent a the report tje OSS in SD sent recommending 2 level ADR even tho he doesn't do it, and that he was referring me out) UR tore that up and non certified what wasn't even a request for authorization for surgery!!!

Anyway, I asked the Claims Adjustor why not tell surgeon who is going to request authorization to do the surgery how to write the admissable report and have it sent back? After all, it is his request that is either going to be certified or non-certified.

I was told "he knows how, he just didn't do it".. so then the topic of settling the claim came up and the Claims Adjustor said that's why I should see the doctor in SD and make him my Primary Treating Doctor as he can write the report, write a plan out along with my PM doc who is in the same building ( I still retain the same PM doc even tho he's 2 hours away as I only have to see him every 3 mo. for scripts).

The whole idea about having a plan on the table with surgery and so forth is supposedly so I would get the most amount of $$ that WC would settle with ..

The Claims Adjustor told me that I would have to see a QME (Qualified Medical Examiner) if I remained with my present Primary Treating Physician even tho essentially he's offering the same surgery except with an implant that is FDA approved for one level use already and a fusion at L5S1, but first he wanted to do a discogram and WC insurance wouldn't authorize it, only the CT scan.

If Prodisc is FDA approved any time soon, why is it just for one level use when the study was a 2 level trial?

Why should I change primary treating physicians just for a report to be written correctly when the surgeon is the one requesting authorization to do surgery so wouldn't UR be either certifying or non certifying what he says, vs. what another person who doesn't even do the surgery says.

Is the Claims Adjustor the one who decides if I see a QME or not?

Is what the QME says binding if it differs from what several surgical consults I've seen more than once have recommended?

** While I have thought it best to go with The Spine Center because of the number of ADR surgeries done there, I know that if Prodisc isn't FDA approved yet, this whole thing will stall anyway and go nowhere and be non certified again.

I will need to appeal a non certification and to do so properly, it appears that the disc should be FDA approved or there should be an incredible amount of Peer Reviewed, published scientific evidence that can back up the choice to use this implant in my appeal.

My current OSS advised me that the Charite disc since being FDA approved for one level might fly with the fusion idea and he thought this ways the only way that the surgery might be approved by UR, but I guess I wanted to believe otherwise.

If I'm not going to have anything authorized, I'd prefer not to change my Primary Treating Physician as he's 5 mins. from where I live and I don't drive distances or have someone that can take me to doctor's appts/distances. WC has been paying for some pretty long distance consults but from what I can recall, I think that transportation over a certain milage must be taken care of by the patient.

But I have to question having a Primary Treating Physician that is 200 miles away...

And I'm quite concerned that any request for authorization for a surgery would go forth, without first requesting authorization to do a discogram first and receiving my BMD results/reviewing them with me by the consulting surgeon (whichever it may be) not another OSS that can write a letter that hopefully gets me more $$ if I settle tho that would be nice if it were true.

I would like to believe the Claims Adjustor has my best interests in mind, however, since I was once employed, I know there is this thing called a "job" and likely if one wants to remain employed, his or her best interests lie with whatever the company desires/requests, not my desires/needs.

My apologies for not being clear here, my mind is spinning, my stomach churning, and I am feeling like a rat trapped in maze with some good or better gates, and others that will electrocute~

[kimber_lee]

Hi Mariaa,

I'm a member of braintalk and I still have access to it. If you want me to post it let me know...

Kimberly

[Mariaa]

Kimberli,
thanks, I tried to clean it up a bit tho don't want to lose too much of the voluminous content.. if you would post it there for replies, I can still read there~ thank you very much~

[ans]

Hi,

Don't mean to interfere but I posted your mssg. to BrainTalk as I'm up late, goofing around. Hope you get good responses.

ans

[kimber_lee]

Allan beat me to it!! Do you ever sleep??!! Just kidding. I was up pretty late myself

Kimberly

[Mariaa]

I got a reply at Braintalk.. which I cannot reply to~ so frustrating.
My WC law firm doesn't take anything that isn't going to make $$ for them so I was asked to send an email with my questions which I've still to do since my moving around so much makes everything so confusing plus the consults here and there..
I actually was hoping TamaraShadow would reply as she's an injured WC attorney and gives the very best advice, and just plain answers to questions...
Oh well, WC is a big freaking PITA!