Your doctor says you need surgery. The Department of Labor & Industries or Self-Insured Employer says no. That leaves an injured worker with an important question: What happens now? In Washington, a denied surgery request can be challenged through a formal protest or an appeal.

Key Takeaways

• A surgery denial is not necessarily the end of the road.
• The reason for the denial can determine your next step.
• Your doctor may be able to provide additional information to support the surgery request.
• Some surgery requests can go through a utilization-review re-review.
• Workers’ Compensation decisions generally have a 60-day protest or appeal deadline.
• Keep copies of your medical records, the denial, and related communications.

Why Would Workers' Compensation Deny Surgery?

When a surgery is denied, the reasoning behind it directly impacts how you move forward with your claim. Common reasons for denial include:

• Your doctor cannot confirm that your condition is related to your workplace injury.
• You are denied coverage for a new condition, even though your doctor believes it is directly related to your workplace injury or illness.
• It is determined that you have reached Maximum Medical Improvement (MMI), meaning your condition is not expected to improve with additional treatment.
• A second medical opinion is being requested before approving a treatment or procedure.
• Your claims manager will not respond to your doctor's request to approve a treatment plan.

How Surgery Authorization Works in Washington

Many surgeries require authorization before they can be performed under a Washington workers' compensation claim. Depending on the procedure, the request may need to go through your claim manager or through utilization review. L&I uses medical treatment guidelines and other criteria to evaluate whether certain procedures should be authorized.

For surgeries subject to utilization review, if the clinical information does not meet the applicable guidelines or criteria, the request can be referred to a physician consultant. The requesting provider can disagree with the determination and request a re-review, which is performed by specialty-matched physicians.

Talk to Your Treating Doctor About the Denial

Before agreeing to pay for surgery yourself, find out who will be responsible for the bill and whether doing so could affect your workers' compensation claim. An attorney can help you understand the potential consequences before you make that decision.

Your doctor may be able to provide more detail about your diagnosis. They could establish a stronger connection between the condition and your work injury. Your doctor can also address the treatments you have already tried. It is important that they explain why those treatments have not worked and why the recommended surgery is now necessary. Their explanation can also include what could happen if treatment is delayed.

Legal Right to Appeal

Workers have the right to challenge a surgery denial, but they must pay close attention to the applicable deadlines. A written protest must generally be received within 60 calendar days of receiving the decision, but the actual order should be checked for the applicable deadline. A lawyer can help you determine the best path for challenging a denial. Under Washington’s L&I process, there may be several options available depending on who issued the decision and the reason for the denial:

• Protesting an L&I decision to the Department of Labor & Industries;
• Appealing an L&I decision directly to the Board of Industrial Insurance Appeals;
• Seeking further judicial review in Superior Court

What Evidence Can Help Challenge a Surgery Denial?

A wide variety of evidence can provide a more comprehensive picture of the situation. Medical records, diagnostic results, and the treating doctor’s recommendations can all be useful. If there is evidence of previous treatments being unsuccessful, this can support the argument that the recommended surgery is the best option. It can also be helpful to have third-party supporting medical opinions that agree with the treating doctor’s recommendation.

Contact a Workers' Compensation Lawyer in Washington

When your doctor says surgery is necessary, a denial should not be something you simply shrug off. There are steps you can take to challenge a workers' compensation decision, but waiting too long or paying for disputed treatment yourself can create additional problems. Find out why the surgery was denied, keep your medical records and communications, and get advice about your options before making a decision.