The Claims Adjuster Said My Surgery Was Denied by Utilization Review—What Can I do?

The Claims Adjuster Said My Surgery Was Denied by Utilization Review—What Can I do?


The place to start is to contact the Law Offices of Marc Francis, your first call for a work injury lawyer in Sonoma County.

Was the Denial Timely?

The first inquiry should be whether the utilization review was done by the workers compensation insurance carrier in a timely manner. If the denial determination was not made within the time allowed by the California Labor Code, then the Workers Compensation Judge has jurisdiction to order the medical treatment to be provided to the injured worker. The time within which the insurance carrier’s utilization review decision must be made can vary according to the particular facts of the case, so we recommend you call our office for a free consultation as soon as you receive notice that treatment has been denied. If the denial was timely, there are other remedies available to you.

Voluntary Appeal by Prescribing Doctor

Request that your treating doctor file an appeal with the utilization review. Some utilization review companies, but not all, have a voluntary appeal process, and it is possible that the doctor can contact the utilization review doctor or nurse to discuss the reason or reasons for the denial and convince them that the treatment should be provided to the injured worker.

File an Appeal with Independent Medical Review

A formal appeal of a utilization review medical treatment denial can be filed by the injured worker, the prescribing doctor, or by the injured workers’ attorney. There are important time deadlines for filing these appeals and important details to be considered when doing so. Contact our office immediately upon receipt of a denial to determine whether a formal Independent Medical Review appeal is the best remedy in your situation.

Ask the Prescribing Doctor Whether The Medical Facts In The Utilization Review Denial Have Changed

If the prescribing doctor can document a medical change in the material facts upon which the utilization review denial was based, there may be a basis for a new request for authorization of the denied medical treatment. For example, if the denial was made on the basis that the findings on diagnostic tests do not support the request for treatment, and those findings have changed since the utilization review denial was made, the prescribing doctor can issue a new request for authorization of the medical treatment.

Ask the Prescribing Doctor to Consider Other Medical Treatment Options

Sometimes your doctor may have other treatment options for your particular needs. These should be discussed with your doctor as soon as possible to allow time for filing a formal appeal, should that be necessary.

Contact a Workers Compensation Attorney in Santa Rosa for Assistance

Utilization review denials of medical treatment in workers compensation cases can be frustrating and complicated. That’s why you should contact the Law Offices of Marc Francis today for a free consultation.

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