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When it comes to getting a claimant's treatment authorized, a doctor must typically submit a request for that treatment in accordance with the New York State workers compensation medical treatment guidelines. A doctor will initially submit a level one request for whatever treatment is being sought. If the level one request is denied by the insurance carrier, the doctor can then escalate that request to a level two for further review. This process can be done up to a level three where the medical
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director's office will then review the request and rule on whether the doctor has met the medical necessity for the request. Should the request be denied by the medical director's office, judicial review can then be requested. I was recently able to have a law judge a approve a s a a shoulder surgery for our client where the insurance carrier repeatedly denied the request and the denial was actually upheld by the medical director's office holding that the doctor did not meet the medical
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necessity for the request under the guidelines. Now, when a doctor requests for treatment under the uh New York State workers compensation cases, specifically a surgery, typically there are certain criteria outlined in the guidelines that me that must be met for such a request to be authorized. In this specific case that I dealt with, the claimant's doctor submitted a request for a left uh shoulder surgery uh typic uh specifically an arthoroscopy. The doctor clearly outlined in his request the
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claimant's physical examination findings over the course of two years. Um positive diagnostic tests inclusive of MRIs and X-rays and failed conservative measures. All of those factors are outlined in the New York State workers compensation guidelines as medically necessary uh for the procedure to be authorized. Uh although the request was taken up to and denied by the medical director's office, we requested on behalf of our client judicial review in front of a law judge um to make arguments outlining how the doctor did
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in fact provide an abundance of medical documentation that establishes a positive correlation between the claimant's clinical exam, course of treatment, and testing to support its request. After summations were given on behalf of the claimant and the carrier regarding this procedure um in front of the law judge, the judge actually found that the carrier and the medical director's uh office were incorrect in denying the procedure. The law judge indicated that the doctor adequately supported the
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request for a left shoulder arthroscopy in accordance with the New York State workers compensation guidelines. Be therefore authorized the procedure for the claimant.
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