UR and IMR don't always work (California) (California) (Cali

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UR and IMR don't always work (California) (California) (Cali

Postby injured7825 on Sun Oct 04, 2015 1:44 pm

I have been fighting work comp for just over 6 years before spine surgery was finally approved and when it was approved, things didn’t go right with the surgery and even more wrong with the UR/IMR process that I think in my opinion shows that the Doctor, claims administrator, UR and IMR possess doesn’t always work and make things a lot worse for the applicant.
This is the timeline of how things went in my case just since the spine surgery on 10/20/2014.

Outpatient Spine surgery for a foraminotomy/Laminotomy of bilateral L4/L5 and left L5/S1 on 10/20/2014, intraoperative dural sac tear & repair, post-op medications were prescribed and not approved or denied and never received.

10/20/2014 went to ER and admitted for high white blood cell count and possible infection due to CSF leak and low pressure headaches, treated with IV antibiotics and pain medication.

10/23/2014 discharged from Hospital after white blood cell count returned to normal.

1st RFA for MRI to assess for a lumbar pseudomeningocele and possible blood patch due to low pressure headaches 11/6/2014.

2nd RFA for MRI to assess for a lumbar pseudomeningocele 11/18/2014.

RFA received by CIGA on 12/01/2014.

Received by CID (UR) on 12/09/2014 and denied on 12/11/2014.

12/16/2014 applicant’s attorney filed for expedited hearing on late UR and delay of treatment.

IMR Appealed on 12/22/2014.

IMR Overturned UR MRI denial on 12/31/2014.

01/29/2015 Hearing minutes MRI was authorized and the use of 2 AME’s approved.

Applicant files Ethic Complaint with CIGA on late MRI and denial on 02/10/2015.

02/10/2015 applicant received UR approval for denied MRI.

02/13/2015 MRI was performed showing clumping nerves roots of the Cauda Equina and suspicious for arachnoiditis at L5/S1 as well as seroma and severe foraminal stenosis at left L4/L5 and L5/S1 indicating the foraminotomy the surgeon did surgery for failed.

On 02/20/2015 Ethic Board notified applicant that the adjuster to contact surgeon saying the MRI was authorized and the 2 AME appointments were set up as well as assignment of nurse case manager and assignment of new claims administrator.

04/29/2015 applicant paid for a second opinion on post-op MRI, recommended a CT/Myelogram to assess for a lumbar pseudomeningocele.

05/07/2015 report notes and an RFA for CT/Myelogram and EMG/NCS was requested per second opinion doctor which the surgeon agreed with.

RFA for CT/Myelogram and EMG/NCS received by CID (UR) on 05/07/2015 and denied on 05/11/2015.

05/18/2015 an IMR appeal was received.

05/22/2015 IMR upheld UR denial of CT/Myelogram and EMG/NCS.

06/09/2015 Primary treating physician submitted an RFA requesting a CT/Myelogram or MRI with contrast to assess for lumbar pseudomeningocele.

RFA for CT/Myelogram or MRI received by CID (UR) on 06/09/2015 and denied on 06/10/2015.

UR Internal appeal for denied CT/Myelogram or MRI received by CID (UR) on 06/18/2015 and upheld on 06/22/2015.

06/22/2015 IMR appeal was received.

06/30/2015 IMR upheld UR denial of CT/Myelogram or MRI with contrast.

Applicant has obtained from his own health care an MRI with contrast on 08/31/2015 showing clumping nerves and persistent findings suspicious for adhesive arachnoiditis at L5/S1, the same as the post-op MRI done on 04/13/2015, a seroma of surgical bed cleared up and severe foraminal stenosis at left L4/L5 and L5/S1 indicating the foraminotomy the surgeon did surgery for failed.

Applicant has obtained from his own health care a CT/Myelogram that was performed on 09/11/2015 showing again L5/S1 suggestive for adhesive arachnoiditis and compartmentalization of the contrast of L5/S1 and L4/L5 suggestive for pseudomeningocele and leaking of contrast outside of the subarachnoid space and severe foraminal stenosis at left L4/L5 and L5/S1 indicating the foraminotomy the surgeon did surgery for failed.

Applicant will obtained from his own health care a pending EMG/NCS to be done on 10/14/2015.
injured7825
 
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