How to get L&I surgery oked that claims manager keeps denying Ortho Specialist has requested 3 times?


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If your claim manager keeps denying L&I surgery that has been requested by an Ortho Specialist, you can try the steps below to increase your chances of getting the surgery approved:

  1. Understand the process: Familiarize yourself with the specific rules and guidelines of your state's L&I system. Each state may have different criteria and requirements for approving surgeries. Knowing these rules can help you make a stronger case.

  2. Gather supporting documents: Collect and organize all relevant medical records, including letters from your Ortho Specialist explaining the necessity of the surgery, X-rays, MRI reports, and any other diagnostic test results. This will provide evidence supporting your need for surgical intervention.

  3. Consult another Ortho Specialist: Consider seeking a second opinion from another Ortho Specialist to confirm the necessity of the surgery. Having two expert opinions can strengthen your case.

  4. Communicate with your Ortho Specialist: Discuss the denial with your Ortho Specialist, and ask them to provide additional documentation or clarification of why the surgery is necessary. Ensure that all the necessary information is being shared and that your Ortho Specialist is aware of the denial.

  5. Understand the reasons for denial: Contact your claim manager or insurance company to get a clear understanding of the reasons for the denial. This will help you address any specific concerns or requirements they may have.

  6. Write an appeal letter: Prepare a formal appeal letter explaining why the surgery is required, citing medical evidence, specialist opinions, and any other relevant information. Clearly address the reasons for denial and provide a compelling argument as to why it should be approved. Ensure the letter is concise, respectful, and well-organized.

  7. Follow the appeals process: Submit your appeal letter to the appropriate party or department, following the specific appeals process outlined by your state's L&I system. Be mindful of any deadlines and requirements for submission.

  8. Seek legal advice if necessary: If you have exhausted all your options and continue to face denials, you may consider consulting with an attorney who specializes in workers' compensation or L&I cases. They can guide you through the legal process and represent your interests.

Remember, each situation is unique, and the process may vary depending on your location and specific circumstances. It's important to consult with professionals who specialize in workers' compensation and L&I cases to ensure you're following the right steps and have the best chance of getting your surgery approved.

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