Compliance of a UR decision (California) (California)

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Compliance of a UR decision (California) (California)

Postby Luckyazkd9 on Fri Sep 25, 2015 5:07 pm

If a UR approved a piece of Medical equipment, who was responsible to provide it? Specifically, a 2009 UR approved a lift recliner which I never received. Who was to make the purchase and payment? I was going through all my UR approvals and denials when I came across this one. I also found one which approved house cleaning twice a week which was never done. Prior to my 2010 four disk fusion with cages I was not in a very stable state of mind because of the pain and medications. The back surgery failed and I have slowly taken myself off some of the drugs and try to deal with the pain. I am most likely SOL because of the time frame yet I remain curious. I thank you in advance for your responces
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Re: Compliance of a UR decision (California) (California) (Calif

Postby Barney5 on Sat Sep 26, 2015 12:39 pm

Hi Lucky,

It has been my experience that the doctors office that made the request usually has connections to DME etc and helps the injured worker by setting this up. Your claims adjuster is not responsible to schedule the surgery, but is responsible for paying for the surgery. It sounds like there was no follow through after the requests were approved through UR, which is unfortunate.

Also, do you still need the chair and cleaning services and has there been a change in your condition or circumstance? Was the approval for cleaning services for post op care for your surgery?

I would discuss this with your attorney and doctor if these are still things you need.
Last edited by Barney5 on Tue Sep 29, 2015 6:38 pm, edited 1 time in total.
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Re: Compliance of a UR decision (California) (California)

Postby Luckyazkd9 on Sun Sep 27, 2015 1:58 pm

Thanks for your reply. The UR approval was pre-surgery as was the housekeeping. I need the lift recliner post surgery as I lose my leg strength by late afternoon. A big factor is how long I was up and walking around. Last doctors visit I requested a prescription so I could go out and buy my own and just include it in my Federal Tax medical deduction. The post housekeeping we have been paying on our own. My wife was wearing herself down trying to do all which is required in the upkeep of a home. All the tasks I preformed as gardening, lawn service, pool maintenance, and handyman home repairs I now have to fund or else have our home goes to pot. Perhaps we should sell and downsize to a unit where everything is included however when I think about someone telling me what color my home should be I find myself rejecting such a concept. It is ok for some however not me. I have strayed off the subject, sorry.
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Re: Compliance of a UR decision (California) (California) (Calif

Postby Barney5 on Mon Sep 28, 2015 6:28 am

Is there a reason why you are not having your doctor request these things again? I recommend it if these are things you still need.

I have seen approvals to help with things like gardening, housecleaning, cooking etc. for those who have severe injuries.
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Re: Compliance of a UR decision (California) (California)

Postby ymcgavin@socal.rr.com on Mon Sep 28, 2015 9:22 am

Luckyazkd9 wrote:If a UR approved a piece of Medical equipment, who was responsible to provide it? Specifically, a 2009 UR approved a lift recliner which I never received. Who was to make the purchase and payment?


Lucky, the question you posed above was answered in 1983, by the Supremes in Braewood v. WCAB (Bolton), 34 Cal.3d 159.

"[T]he employer is given initial authority to control the course of the injured employee's medical care. (Voss v. Workmen's Comp. Appeals Bd. (1974) 10 Cal.3d 583, 588 [111 Cal.Rptr. 241, 516 P.2d 1377]; McCoy v. Industrial Acc. Com. (1966) 64 Cal.2d 82, 86 [48 Cal.Rptr. 858, 410 P.2d 362].) Section 4600 requires more than a passive willingness on the part of the employer to respond to a demand or request for medical aid. (McCoy, supra, at p. 89; Myers v. Industrial Acc. Com. (1923) 191 Cal. 673, 679 [218 P. 11].) This section requires some degree of active effort to bring to the injured employee the necessary relief. (Myers, supra.) Upon notice of the injury, the employer must specifically instruct the employee what to do and whom to see, and if the employer fails or refuses to do so, then he loses the right to control the employee's medical care and becomes liable for the reasonable value of self-procured medical treatment. (Voss, supra, 10 Cal.3d at p. 588; McCoy, supra, 64 Cal.2d at p. 86; Draney v. Industrial Acc. Com. (1949) 95 Cal.App.2d 64, 67-68 [212 P.2d 49]; County of L. A. v. Industrial Acc. Com. (1936) 13 Cal.App.2d 69, 74 [56 P.2d 577].)"
(Braewood, supra, at pg. 165)

http://scocal.stanford.edu/opinion/brae ... s-bd-28367 (I posted this link to the case, instead of attaching a copy, should WCC remove the attachment due to copyright issues.)

Braewood was decided long before UR existed, but the principle that LC 4600 requires "more than a passive willingness" on the part of the employer, and instead "requires some degree of active effort to bring the injured employee the necessary relief" is particularly poignant today, considering the fact that the MPN model encompasses not only physicians, but also pharmacy benefit managers and preferred DME providers.

If I were standing in your shoes, I would make one written demand to be have the employer (insurer) provide the recliner approved by UR, with a copy of the UR authorization attached, then if there is no response from the employer (insurer) within 30 days, I would go purchase one myself and send the bill to the employer (insurer) with a demand for reimbursement. As always, I would send all correspondence via certified return receipt mail, with a POS signed and dated by someone other than yourself.

I do note you stated the UR approval was prior to surgery in 2009, as well as the fact you were "not in a very stable state of mind because of the pain and medications" at that point in time. However, we are now 5 years down the road. You may want to read, or have your wife read, correspondence from the insurer or UR, a wee bit more timely.

York McGavin
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Re: Compliance of a UR decision (California) (California) (Calif

Postby Barney5 on Mon Sep 28, 2015 12:09 pm

York, this is excellent advice and much better than to risk it again with UR and possibly IMR!
Lucky, I would recommend to disregard what I wrote and follow the advice York gave. I hope you prevail if you decide to move forward with this through the work comp system.
I will also save this case and info.
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Re: Compliance of a UR decision (California) (California)

Postby Luckyazkd9 on Fri May 13, 2016 9:16 pm

I went out and purchased a lift recliner in Dec. 2016 after receiving an other prescription dated Nov. 16 2015 from my PTP for a lift recliner. I submitted, to my AA the new prescription, purchase invoice, proof of payment and a copy of the certified UR for a lift recliner. I wrote a very detail letter to my AA explaining all the event and requested he seek the reimbursement of $500 (The UR approved amount). The lift chair cost was $979 plus tax and delivery. He immediately filed for a MSC and on the morning of the MSC called me and told me he could not ask for reimbursement because a UR decision was only good for one years from the date of the UR issue. It was evident he had not re-read my letter as a new prescription was attached to it. He also told me my files took up eighteen boxes and he could not re-read my current documents. Yes, after sixteen years as an injured worked my home files occupy a whole three drawer file cabinet. As if I wished myself to be in the situation. Just a note, today I received a UR non-certification of my major pain killer Tramadol. My PTP switched me from Norco to Tramadol for my failed back surgery. I only take two or three pills in a twenty four hour period so I don't think it excessive. Well an other battle in the Workers Comp. system. Do I dare switch AA after sixteen years? Excuse my rambling please.
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Re: Compliance of a UR decision (California) (California)

Postby LawAdvocate on Tue May 17, 2016 4:11 pm

No, probably not wise to switch AAs after 16 years. A mere prescription is not enough. If the UR certification had expired, your PTP had to also prepare a new RFA substantiating why 7 years post surgery the recliner was still required. This can still be done, it will be a retroactive UR request, but the prescribing physician must prepare a valid RFA and the insurance company would then have 30 days to respond.
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Re: Compliance of a UR decision (California) (California)

Postby Barney5 on Mon May 23, 2016 2:48 pm

I highly recommend contacting your doctors office about the UR denial for your medication and ask them to do an internal UR appeal ( you have 10 days after UR denial date). If you want to go further, you can review the rational that was used to deny the medication and supply any records to your doctor that may address the denial. If the internal UR appeal is also denied, you can request an IMR. Directions on how to do both are located on the last few pages of your UR denial.

I remember a discussion about UR approval expiration dates on this forum, and do not recall seeing anything that stated a UR company can place expiration dates on UR approvals. I will try to find this post. If anyone has any input on this I would appreciate it. How long had it been since the UR approval expired?

"LawAdvocate" gave some good advice on a way to do a retroactive UR request. I would recommend sending in the original UR approval with the request.

I would not recommend changing your attorney unless he stops working for you.
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