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B.R., Queens

Off The Record – Workers’ Comp – Medical Treatment

Video Transcript

Hi, everyone, Craig Rosasco, law firm Turley Redmond & Rosasco, workers’ compensation attorneys located all throughout New York State, and most specifically, here on the island of New York City.

What we’re going to talk about today is treatment and medical treatment that comes with a workers’ compensation claim. Not a day goes by that I don’t get a phone call from somebody saying, “Ah, they’re denying my treatment. I’m not getting the right amount of treatment,” blah, blah, blah. There are treatment guidelines that dictate how much and what type of treatment you are entitled to and your doctors and providers are supposed to be adhering to those guidelines.

So let’s take a typical example that I get every day. A person gets hurt at work, they injure their back, okay? They go for physical therapy. They get hurt, let’s say, November of 2022, so last year. They go for physical therapy for six months. They’re still not getting better. However, they want to keep going to physical therapy under the hypothesis that it’s going to work at some point.

So in order to get more physical therapy, the treatment guidelines say “Automatically, pre-approved, six to eight weeks. Go get your six or eight weeks.” If after the six or eight weeks you can show what’s called “objective functional improvement,” then your doctor files to get more PT and you’re entitled to get it. He’s going to say, “The range of motion inflection in the back went from 40 degrees up to 60 degrees. That’s his functional improvement. He’s got better ADLs, which is activities of daily living. He could sit longer, he could stand longer, he could walk longer. He could do all these different things.”

Now that you’ve shown the improvement, you are entitled to more physical therapy. If at the beginning of your physical therapy, you were able to flex to 40 degrees, and at the end of 8 weeks of physical therapy you’re still able to flex to 40 degrees, there’s no improvement. They’re not going to give you more treatment, okay?

Next rung on the ladder for a back injury is going to be pain management. That’s where you go off and you get injections, whether they be epidural steroid injections, facet block injections, radio frequency ablations, trigger point injections. They’re all different modalities of treatment that are available to people on that second rung on the ladder. Because remember, physical therapy didn’t work, you go to the next rung on the ladder, it’s pain management.

Pain management doctor can get you all those and get pre-certified for those. There are certain items that are pre-certified under the guidelines. Typically, one epidural steroid injection is pre-approved. If you show more than 50% relief from that first one, the doctor can go on to secure a second one based upon the improvement that they showed. And then last but not least is surgery.

So at the three-year anniversary of your claim, are they looking to give you more physical therapy? Absolutely not. I have clients all the time that say, “I went to physical therapy for nine months and I need more therapy.” I say, “Well, did it work?” And then I review the records. There was no improvement. The patient’s still complaining of pain. They’re still totally disabled. There’s been no reduction in their overall impairment.

So keep in mind, if you’re showing the insurance company that you’re improving, there’s a thought process that if you’re improving, your disability is going down, that may affect your payments. So keep that in mind.

Last but not least, what did I want to speak to you about? The other issue is when you get hurt at home and you go for back treatment through your private insurance, whether it be Aetna, Blue Cross Blue Shield, Empire Plan, typically those insurance companies, they give you 10 to 20 visits per year. Not a day goes by and my client’s like, “I’ve been going for nine months. I go three times a week for nine months.”

So let me get this straight. Nine times…. So you’re in about 40 weeks times 3. You’re at 120 visits. If you got hurt at home, you get 10 to 20. You’re at 120 visits and you’re still saying you need more and it’s not fair. We need to talk. Okay. We need to understand what the law provides and what it permits. I know the medical treatment guidelines. It’s my job to inform you as to how they work and how you can navigate yourself through it.

So if you’re in this predicament, call me. I’ll walk you through it. I’ll get you whatever you’re entitled to. 516-745-5666. Call me. You won’t be disappointed.

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