Surgical Consult on 10 year old case (1998 DOI) (California)

[bradley]

I have two questions....

I have a 1998 case where the P.T. (who is no longer performing surgeries) is recommending that Applicant undergo another surgery and referred Applicant for a Surgical Consult with a Surgeon who is not on carrier's MPN network. Carrier does not want to authorize and told Surgeon's office that case was closed....

My first question is whether that's a request for surgery itself under Labor Code Section 4062(b) or is it just a request under 4610?

My second question is since this is a 1998 injury case, do I need to make sure this referral goes through the Carrier's MNP network?

[stewshe@comcast.net]

bradley,

You don't give enough info to answer your questions.

Has there been an award with open meds? If so, and if it involved the body part(s) in question, it is irrelevant if the carrier closed its file. All they need to do is to reopen it!

What kind of surgery is proposed? A carpal tunnel surgery or spinal surgery? Makes a difference, since different code sections, timelines and procedures apply.

Has UR issued a timely denial?

Was there an AME? If so, go back to AME to resolve disputes over treatment.

Has the EE been given notice of the MPN? If not, then MPN does not apply.

If notice has been given, does the EE have a serious chronic condition? If so, the PTP can continue to treat and make referrals. The MPN will apply ONLY if all the "i's" have been dotted, etc.

Good luck!

[Zemizy]

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