Getting hurt at work is already stressful. But it becomes even more frustrating when you find out that the surgery your doctor recommended is being denied by workers’ comp. If you’re dealing with this in Los Angeles, you’re not alone. There are steps you can take to fight back and get the treatment you need.
Who Can Deny Surgery or Treatment?
In California, the workers’ compensation insurance company often makes the decision to approve or deny medical treatments. This includes surgery. The decision is usually based on reports from your treating doctor and sometimes from another doctor hired by the insurance company.
A claims adjuster, who works for the insurance company, reviews your medical records and makes the call. They might also send you to an independent medical examination (IME). That’s when another doctor checks you and gives their opinion about whether the surgery is really needed.
Common Surgeries Covered by Workers’ Comp
Not every surgery is automatically approved, even if your doctor says you need it. Some of the common types of surgeries that may be related to work injuries include:
- Back and neck surgeries (like spinal fusion)
- Carpal tunnel release
- Knee or shoulder repairs
- Skin grafts for burns
- Surgery to treat eye or brain injuries
- Bone repair or joint replacements
- Reconstructive surgery after serious trauma
If the surgery is related to your job injury and is considered “reasonable and necessary,” it should be covered by workers’ comp.
Reasons Your Surgery Might Be Denied
There are several reasons an insurance company might deny your surgery. Sometimes, it’s a simple paperwork issue. Other times, it’s more complex.
Here are some common reasons:
- They don’t believe the injury is work-related. The insurance company might argue that your injury happened outside of work.
- They think the surgery isn’t necessary. An insurance doctor may say the treatment is too extreme or that another method, like physical therapy, should be tried first.
- You were under the influence at the time of injury. If the insurer thinks drugs or alcohol played a role in the accident, they may deny your claim entirely.
- You missed a deadline. There are strict timelines in workers’ comp cases. Missing a filing deadline can lead to a denial.
- They say you’ve already reached “maximum medical improvement” (MMI). This means they believe further treatment won’t help.
What You Can Do After a Denial
If your surgery is denied, don’t panic. There are options available. You have the right to challenge the decision.
Here are a few steps you can take:
- Ask for the denial in writing. This should explain the reason for the denial.
- Get a second opinion. Another doctor might support your case and provide new documentation.
- Gather all medical records. These records can help show the surgery is necessary for your recovery.
- File an appeal. In California, you can appeal the denial through the Division of Workers’ Compensation (DWC). This can include requesting a hearing or asking for a second-level review of your treatment denial.
- Talk to a workers’ comp lawyer. A lawyer can help you build a strong case with expert opinions, test results, and paperwork.
How You Might Still Qualify for Benefits
Even if your surgery is denied at first, that doesn’t mean your benefits are gone forever. If you follow the right steps, you may still be able to:
- Get the surgery approved later
- Receive reimbursement if you paid out of pocket
- Access other forms of treatment in the meantime
- Get temporary or permanent disability benefits
You don’t have to accept the first “no” from the insurance company. Many cases are overturned after an appeal or with legal help.
Talk to a Los Angeles Workers’ Comp Lawyer
If your surgery was denied by workers’ comp, it’s time to get help. Going through this process alone is hard, especially when you’re dealing with pain or stress from the injury. Our legal team understands California’s workers’ comp system and knows how to push back against unfair denials.
We can help you gather the right medical records, request the proper hearings, and fight to get your treatment approved. Don’t wait while your condition gets worse. Call (323) 954-1800 today to schedule a free consultation and find out how we can support you.