Employers have a right to contest the payment of both indemnity and medical benefits. Medical treatment can be contested for reasons ranging from incomplete paperwork, to the treatment being inappropriate for the injury, or to the doctor not being approved. In some states, they have what is known as utilization review (UR). During UR, an employer or insurance carrier can remove certain medications or treatments from your treatment plan, meaning they would no longer be covered.
If you are looking for treatment inconsistent with a UR recommendation, your request may be challenged. Usually when treatment is contested, your employer must inform your state’s workers’ compensation agency of the challenge and explain why. All states have formal procedures allowing an injured worker to contest the denial and explain why the treatment should be allowed. If your claim is settled and some of the settlement proceeds are earmarked for future medical treatment, your post-settlement treatment is at your discretion and that of your physician. If you settle your claim with a Medicare Set Aside (MSA), you will need to ensure all treatment the MSA funds pay for is related to your initial injury, and are an expense Medicare covers, in accordance with the Centers for Medicare and Medicaid Services’ (CMS) guidelines. You can find out more about Medicare Set Asides here.