Before the implementation of the Medical Treatment Guidelines, patients in New York State Workers’ Compensation cases were often afforded lumbar fusion surgery. However, since the Guidelines became effective, it is much more difficult to get lumbar fusion surgery approved.
Under A.14 a lumbar fusion is listed as one of the specific medical procedures requiring pre-authorization. Unfortunately, most insurance carriers will deny authorization for lumbar fusion surgery and will secure a medical opinion from their paid consultant. That opinion usually recommends against the surgery and begins a spiral of litigation.
Following the litigation process, which can take anywhere from two to nine months, or longer, an Administrative Law Judge will make a ruling as to whether the fusion surgery must be covered or not. The litigation process often includes deposition testimony from the requesting physician as well as the independent medical examiner.
If you need a lumbar fusion as a result of a work related injury and are not sure what steps to take, feel free to contact our firm.