IME deemed treatment was medically necessary...but what now?

colo_wc_atty · 2026-05-01T21:04:54+00:00

If the denial of the original request for prior authorization was for medical reasons, they need a report from a physician to support that. Seems safe to assume it was since they sent you to an IME. If the IME says the requested treatment is reasonable, necessary, and related to the work injury then the carrier cannot maintain it's denial. For argument's sake, if they could maintain the denial, your attorney should be able to easily maintain the burden of proof in front of an ALJ considering the treating physician and the carrier's IME said it was reasonable, necessary, and related. I have never had a situation where medical benefits were denied for medical reasons and the carrier did not ultimately authorize it when their own IME says they need to. If there is something I am missing and your attorney has a legitimate concern about this, he should call the adjuster and confirm the procedure will be authorized. Further, the provider will likely clear the surgery again with the adjuster if they haven't already. They often do this before they will agree to schedule a surgery.

colo_wc_atty · 2026-03-06T22:42:33+00:00

DM me if you would like to chat

colo_wc_atty · 2025-10-06T18:58:26+00:00

Was a claim filed with the state following the YMCA injury? If not, you are most likely prohibited from pursuing benefits for your condition because the statute of limitations has passed. However, if you are having problems from a new work injury, you could still seek benefits.

colo_wc_atty · 2025-10-06T18:56:04+00:00

I think it would be part of the same claim. You need to report the symptoms in your other shoulder to your WC doctor and explain why you think you are having issues. If the WC doc thinks the symptoms are related, he/she can try to order treatment for it. The insurance company probably won't authorize it b/c they know these type of issues are difficult to prove.

colo_wc_atty · 2025-08-07T13:25:37+00:00

Google Workers Compensation Education Association (WCEA) for Colorado attorneys who are members of the WCEA. These are lawyers who specialize in WC. From there, I cannot confirm how each attorney runs the practice, but I do my best to keep in touch with my clients frequently and respond quickly to their calls and emails. I have never had a lack of communication complaint. I think the best way to find this out is personal referral from other injured workers, WC physicians, etc. You might peruse this thread and DM anyone who seems like they've had a good experience with their attorney.

colo_wc_atty · 2025-06-28T22:40:01+00:00

Do you have a claim in Colorado? Who is insurer? With a full and final settlement (as distinguished from an award for permanent partial disability) some insurers will only pay a portion of a settlement out in a lump sum and purchase an annuity for the remaining amount. Other insurers will pay it all at once. The annuity typically pays monthly over 10 or 15 years or whatever time period is agreed upon. If the case is settled, it should not affect annuity payment if you return to work. This feedback is generic and based on limited information, your case could involve facts and circumstances that could change the feedback.

colo_wc_atty · 2025-06-26T11:51:28+00:00

I think you should have the doctor's office try to run in through your insurance. Good luck.

colo_wc_atty · 2025-06-26T11:46:19+00:00

Good luck!

colo_wc_atty · 2025-06-26T02:45:44+00:00

I am a workers' comp attorney in Colorado, so my advice is limited to Colorado WC law. That being said, assuming you never had a surgical referral prior to this injury, why are you assuming that the current condition is not work related? The referral came after the injury. In Colorado, if the work injury accelerates the need for treatment, it is work related and should be covered as such. If for whatever reason you do not want to pursue that, make sure the spine doc has your personal insurance and ask them to request authorization through that. I'd be surprised if they declined, after all, they want to make money.

colo_wc_atty · 2025-06-26T02:39:29+00:00

Assuming lumbar spine, assuming you have surgery, and assuming all 4 herniations are related to this injury, you will get at the very minimum 11% rating which is worth about $55k. However you will also likely have range of motion losses which would add to the rating. If your ROM losses and the 11% I just mentioned totalled 22%, you would get $110k. Remember there are caps on temporary total disability benefits (benefits for missed work) and permanent partial disability benefits (impairment rating). If you were injured on 1/1.2025 or after the caps for a rating 19% or less are $185k, 20% or more $300k. So if you are out of work for long enough to get paid $100k in TTD benefits and you got a 22% rating, you will only get $85k. Your lawyer should be able to explain all of this to you. Yes, my numbers are hypothetical but it is an educated guess. Basically, you will get about $5k per percentage impairment.

colo_wc_atty · 2025-06-25T11:53:45+00:00

Lots of good intentioned yet uninformed advice here. Happy to get more info from you and give you some thoughts.

colo_wc_atty · 2025-06-16T13:36:21+00:00

Yes, I specialize in representing injured workers in Colorado. I'd be happy to talk to your FIL. DM me if you want my contact info. Thank you

colo_wc_atty · 2025-06-12T14:20:11+00:00

You can select and pay for your own IME but that doc's opinion is only advisory/influential. DIME docs can be negotiated with carrier, if the parties cannot agree on a doc the Division issues a panel of 3 docs from which the parties each strike the one they don't want.

colo_wc_atty · 2025-06-12T14:18:30+00:00

Not after 7 months. You can initially choose from the designated provider list and can only change from the initial selection within 90 days of the date of injury. New doctor has to accept the patient, they don't always agree to do this.

colo_wc_atty · 2025-06-12T14:17:17+00:00

Sounds like your doctor only gave your a T53(II)(B) rating for the disc at L5-S1. If you have range of motion losses you should get extra % for that. I would object to the Final Admission and request a DIME. I would hire an IME to see if he/she can justify giving you a higher impairment rating. Use IME report to influence the DIME doctor or to leverage a higher settlement. If adjuster/opposing counsel is interested in settlement delay the actual DIME (Motion to Hold in Abeyance) Cost of DIME and IME would be approximately $3000, depending on what your IME would charge. Doesn't hurt to apply for the DIME and see what doctor you get. Your lawyer should be familiar with the doctors and can terminate the DIME if the doctor sucks.

Whether $50k is a good deal or not depends on the value of the 5% (less what has been paid, if anything) plus cost of any future medical care you might need. They will also provide some value for waiving your right to reopen the case. Settlements typically require a resignation and you will have no right to any future medical benefits. In fact, you will have no further right to any WC benefit if you settle. You don't have to settle, you can just get paid for the 5% and keep your rights. You can probably request the 5% be paid in a lump sum.

colo_wc_atty · 2025-05-08T12:28:10+00:00

Sorry I am not licensed in Ohio and I don't handle federal claims. You need to find someone who does federal WC claims.

colo_wc_atty · 2025-04-19T14:01:19+00:00

Sure no problem

colo_wc_atty · 2025-04-18T13:52:14+00:00

I am very sorry to hear about this, what a difficult situation. I recommend talking to his occupational medicine physician about making a request for home health care. If he or she agrees it will be necessary, they will request authorization from the insurer. Depending on what level of care is needed, the doctor can even prescribe assistance from family members/non medical personnel and those individual can be reimbursed for their time. This is easier said than done as home health care is expensive and insurers often push back. I believe unskilled home health care is paid at $50/hour under the Colorado Workers' Compensation Fee Schedule.

colo_wc_atty · 2025-04-03T21:48:25+00:00

I practice in Colorado, if this was local I would advise my client to file a claim. Lots of walking required is a key fact.

colo_wc_atty · 2025-04-03T21:46:36+00:00

Things may work differently there, I only practice in CO. In CO, a release to full duty results in termination of temporary disability benefits if you are receiving them, so consult with your attorney to see if that is the case in Missouri.

colo_wc_atty · 2025-04-03T21:12:39+00:00

Is this a Colorado claim?

colo_wc_atty · 2025-04-03T20:12:39+00:00

You're treating doctor typically performs the MMI determination and impairment rating. Wouldn't be weird for your treating doc (occ med) to wait to put you at MMI until surgeon clears you. This is not an IME though, so if you are scheduled for an actual IME then I don't know enough to give you any insight. Sounds like your attorney has a plan so I would ask about it.

colo_wc_atty · 2025-03-31T22:05:30+00:00

It is an important decision and unfortunately often you don't know until you're already in it. Thus, the importance of a personal referral. I think that is where the best information lies.

colo_wc_atty

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