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I've been denied recommended injury treatment. What now?

Medicine is a science. Or, it's an art. Maybe it's both. Insurers and medical practitioners can't achieve consensus. The disagreement has special implications for New York workers injured on the job.

Workers' compensation mandates coverage for medical treatment for work injuries – within set guidelines. If you and your doctor decide to stray from the treatment listed in those guidelines, the insurance company may deny payment for that treatment. In some such circumstances, seeking a variance might be necessary.

What the standards say

In New York, a new set of medical treatment guidelines have been put into effect in the last year. The New York Workers' Compensation Board requires doctors to follow certain guidelines when applying treatments for injuries to the following:

  • Mid and low back
  • Knees
  • Shoulders
  • Neck
  • Wrists

Of course, many doctors argue that not everybody responds the same to treatment. Sometimes doctors recommend treatments that deviate from the standard but which practice has shown can work. If that leads to a denial of a claim, it's important for injured workers to understand all options, including how to go about seeking a variance.

Seeking a deviation

By law, providers can seek a variance if the recommended treatment is not within the guidelines but is medically necessary. However, restrictions apply.

  • The request, using the proper form, must be made and approved before treatment starts.
  • If care that diverges from the standard has already been delivered, the variance request will be void.

Further, the provider bears the obligation of showing why a variance is appropriate. Also, any request made must:

  • Explain the provider's medical opinion for why the deviation is necessary and provide supporting documents
  • Show why medical treatment guidelines are insufficient
  • Confirm that the patient agrees to the treatment

The process is complicated and one misstep can doom a request. This makes it important to work with experienced legal counsel.

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